POSTCHOLECYSTECTOMY SYNDROME: UNDERSTANDING THE CAUSES AND DEVELOPING TREATMENT STRATEGIES FOR PERSISTENT BILIARY SYMPTOMS AFTER GALLBLADDER REMOVAL.

Persistent biliary symptoms following gallbladder removal, known as postcholecystectomy (PCS), can significantly impact patients' quality of life. The term PCS describes biliary symptoms that emerge or continue after the surgical removal of the gallbladder. Cholecystectomy is generally a safe procedure; however, some individuals may still experience symptoms of the biliary system thereafter. Biliary stones are more likely to be retained in patients who arrive later. Many of those people won't have a known reason for their condition. Therefore, this group will have fewer therapy alternatives. After a cholecystectomy, up to 10% of individuals may develop PCS. Patients with cholecystectomy procedures can appear with extra-biliary and associated biological illnesses. A wide range of therapeutic options are available for PCS, each having a different chance of being the cause of the condition. The purpose of this study is to present an overview of the many causes of PCS, as well as the effectiveness and prevalence of various treatments. PCS has a variety of etiologies, many of which may be related to extra-biliary reasons that may exist before the operation. From the beginning, an endoscopy of the upper gastrointestinal tract may be necessary when symptoms first appear. Biliary rocks are more likely to be retained in patient presentations that are postponed. PCS has various causes, including extra-biliary conditions that could have existed before operations. Initial symptoms might involve higher digestive problems. As a result, this group will only have a few therapeutic alternatives.

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.

Cystic duct stones in postcholecystectomy Mirizzi syndrome - A novel endoscopic treatment.

Mirizzi syndrome is a rare type of cholelithiasis, and the main treatment is still surgery. The development of endoscopic technology has made surgeons more active in the management of rare diseases of the biliary tract and pancreas. Here we report that our center applied the new endoscopic method to treat a Mirizzi patient with residual cystic neck duct stones after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy for remnant gall bladder.

Laparoscopic cholecystectomy is one of the most frequently performed minimally invasive interventions. Inflammation during acute or subacute cholecystitis and fear of biliary duct injury can lead to unintentional remnant gall bladder retention. Diagnosing a remnant gall bladder can be challenging, and misdiagnosis or delayed diagnosis is common. Once diagnosed, completion of the cholecystectomy is recommended, which can be performed laparoscopically.

Late postcholecystectomy Mirizzi syndrome due to a sessile gall bladder remnant calculus managed by laparoscopic completion cholecystectomy: a feasible surgical option.

Postcholecystectomy Mirizzi syndrome (PCMS) is an uncommon entity that can occur due to cystic duct stump calculus, gall bladder remnant calculus or migrated surgical clip. It can be classified into early PCMS or late PCMS. It is often misdiagnosed and the management depends on the site of impaction of stone or clip. Endoscopy can be performed for cystic duct stump calculus. However, surgery is the treatment for remnant gall bladder calculus. Role of laparoscopic management is controversial. We present here a case of a 48-year-old woman with late PCMS due to an impacted calculus in a sessile gall bladder remnant following a subtotal cholecystectomy, managed with laparoscopic completion cholecystectomy, review the literature, provide tips for safe laparoscopy for PCMS and summarise our algorithmic approach to the management of the postcholecystectomy syndrome.

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.

[POSTCHOLECYSTECTOMY SYNDROME: CLASSIFICATION, THE RISK FACTORS, CRITERIA OF THE DIAGNOSIS ESTABLISHMENT, TREATMENT-DIAGNOSTIC ALGORITHM].

Own experience of surgical treatment of patients for postcholecystectomy syndrome (PCHES) in a 2010 - 2015 yrs period was enlighten. The PCHES modified classification was adduced, the immediate and remote results of the patients' treatment were analyzed, technical aspects and peculiarities of performance of some operative interventions, the risk factors for the PCHES occurrence were analyzed.

THE VALUE OF DEFORMATION OF THE BILE DUCTS IN THE DEVELOPMENT OF POSTCHOLECYSTECTOMY SYNDROME.

The aim of this study was to study meaning of bile ducts angulation in postcholecystectomical syndrome developing. MATERIALS AND METHODS: There were 27 patients to be followed-up, 15 of them were performed long-term multi-stent placement in order to pursue bile ducts angulation to be liquidate and angles. After that control estimation was having versus 12 patients of control group. RESULTS: Author have seen diminish average amount of angles, their increased and accelerate of evacuation contrast speed into duodenum. That all have correlate with severe of postcholecystectomical syndrome and positive dynamic. CONCLUSION: The bile ducts angulation have meaning in postcholecystectomical syndrome developing and long-term multi-stent placement is effective way of its treatment.

Utility of endoscopic ultrasound to diagnose remnant stones in symptomatic patients after cholecystectomy.

BACKGROUND AND STUDY AIMS: Stones in the cystic duct stump (CDS) or gallbladder remnant after cholecystectomy are difficult to identify. The aim of this study was to evaluate the utility of endoscopic ultrasound (EUS) in the diagnosis of stones in the CDS or gallbladder remnant in patients with postcholecystectomy syndrome. METHODS: A prospective study was conducted between January 2011 and December 2012 in consecutive patients with pancreaticobiliary-type pain or acute pancreatitis (n = 112) following cholecystectomy. Diagnostic modalities including EUS were used to diagnose the cause of postcholecystectomy syndrome. RESULTS: A total of 11 patients (10 %) were found to have stones in the gallbladder remnant (n = 8), CDS (n = 2), or both (n = 1). In eight patients, EUS was the first imaging procedure to make the diagnosis. Seven patients agreed to undergo repeat surgery, and six of them remained free of symptoms postoperatively after a median follow-up period of 4 months (range 1 - 13 months). CONCLUSION: EUS may be an important procedure to consider in the study of patients with symptoms after cholecystectomy, as the diagnosis of residual stones is frequently missed by other imaging modalities.

Surgical and endoscopic management of remnant cystic duct lithiasis after cholecystectomy--a case series.

INTRODUCTION: Postcholecystectomy syndrome (PCS) as a result of remnant cystic duct lithiasis (RCDL), or gallstones within the cystic duct after cholecystectomy, can cause persistent or recurrent symptoms after cholecystectomy. STUDY DESIGN: A retrospective descriptive analysis was performed for all patients with RDCL at a single institution between 2001 and 2012. Details of presentation, diagnosis, and surgical and endoscopic treatments, and outcomes were collected and analyzed. RESULTS: Twelve patients with RCDL were identified. The interval between cholecystectomy to RCDL discovery was 34.2 months (range 0.5-168 months). On a standard liver enzyme panel, 75% of patients had derangements in ≥1 indices, with the most common single laboratory test abnormality occurring in gamma-glutamyl transferase (GGT) (80%). Eight operative reports noted that the cystic duct was noticeably dilated at the time of cholecystectomy. Two patients developed a cystic duct leak (Strasberg type A bile duct injury) postoperatively, which was managed nonoperatively. Six cases of RCDL required surgery, and six were managed endoscopically. CONCLUSION: RCDL is a potential cause of postcholecystectomy syndrome, but the true incidence is unknown. Laboratory analysis and imaging are helpful in establishing the diagnosis of RCDL. Endoscopic therapy has a role in the treatment of RCDL, but surgical excision of the remnant cystic duct lithiasis may be required.

[Peculiarities of performance of endoscopic transpapillary interventions in the early period after cholecystectomy].

The peculiarities of performance of endoscopic transpapillary interventions (ETI) during the early period after cholecystectomy were studied up. There were examined 1788 patients, aged from 18 to 90 yrs old, in whom postcholecystectomy syndrome was diagnosed. Emergent interventions were performed in 780 (43.6%) patients (main group). Into the comparison group 1008 (56.4%) patients were included, who were admitted to the hospital in 0.5-552 (Me 36) months after cholecystectomy conduction. The indications to perform the urgent endoscopic intervention were excessive transdrainage biliary output (more than 350 ml a day) from a subhepatic indignation (in 442 patients) and the obturation jaundice presence (in 338). Using ETI the cause of biliary obstruction in the early postoperative period was established in 93.5% of patients. Miniinvasive methods were applied in 82.2% patients of the main group and in 93.4%--of the comparison group.

Stump stone 6 years after cholecystectomy: a possibility.

Calculi in the cystic duct remnant are one of the causes of postcholecystectomy syndrome. A 36-year-old woman presented thrice to the casualty department with right upper quadrant pain at an interval of 2 months every time. Ultrasound and CT scan of the abdomen was normal except for echoes in the gallbladder region may be clips. She was treated conservatively and discharged the first two times. The second time, the MR cholangiopancreatography was normal. She had undergone endoscopic retrograde cholangiopancreatography with sphincterotomy with stent in situ outside elsewhere before presenting to us for the third time, which was removed after 6-weeks. The third time, she was taken up for laparoscopic stump exploration, which revealed a stone, which was the cause of her pain. To conclude, stump stone can be a possibility of post cholecystectomy syndrome even after 6 years, and surgeons should be aware of it.