[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.

Evaluation of gastroesophageal reflux after laparoscopic cholecystectomy using combined impedance-pH monitoring.

BACKGROUND AND AIM: Postoperative gastroesophageal reflux (GER) is one of the causes of post-cholecystectomy syndrome (PCS). Reports studying the effect of cholecystectomy on GER show conflicting results and only a few studies have used the more sensitive technique of combined impedance-pH monitoring. This study aimed to study the effect of laparoscopic cholestectomy on GER (acid/non-acid reflux) using impedance-pH monitoring. METHODS: Sixty three consecutive patients of symptomatic cholelithiasis were evaluated. All patients underwent esophageal mannometry and 24-hour impedance-pH monitoring pre- and postoperatively. Frequency scale for the symptoms of GERD (FSSG) scoring was also done in each patient pre- and postoperatively. RESULTS: Out of sixty three patients, four developed symptoms of reflux postoperatively as detected by FSSG scoring. However, no significant changes were observed in lower esophageal sphincter (LES) characteristics, acid and non-acid reflux characteristics, total number of reflux episodes, or in the physical character of the refluxate following laparoscopic cholecystectomy. Significant decrease in the proximal acid reflux episodes was observed. CONCLUSION: The chemical characteristics (acid or non-acid reflux) as well as physical properties (liquid, gas or mixed) of reflux episodes remain unaffected following laparoscopic cholecystectomy. Cholecystectomy itself doesn't increases GER.

[Risk factors and mechanisms of the postcholecystectomy syndrome development in children].

Cholelithiasis has long ceased to be casuistry in childhood. In connection with the steady tendency for it to grow, it has increased the number of surgical interventions on the occasion of holelitiazis. The removal of the gall bladder in some patients is accompanied by disorders on the part of the digestive system, identified as postcholecystectomical syndrome. The article describes the risk factors and mechanisms of the formation of the postcholecystectomical syndrome in children.

[Performance of laparoscopic cholecystectomy for cholelithiasis. Analysis of immediate results].

The results of laparoscopic cholecystectomy (LCHE) performance in 142 patients in 2004 - 2008 yrs were analyzed. The operation duration had constituted 25-95 min, 25 min at average, depending on severity of the gallbladder and surrounding tissues morphological changes. Uncomplicated postoperative course was noted in 135 patients. Early postoperative complications had occurred in 7 (4.9%) patients, including the liquid pooling in subhepatic recessus--in 2 (1.4%). The conduction of a detailed analysis of any complications and mistakes, occurring intraoperatively, permits to omit them. The studying and analysis of complications, in a frame of specificity of intraoperative faults committed during LCHE performance, would make possible to improve the quality and the results of operative treatment of cholelithic disease.

Patients' quality of life after laparoscopic or open cholecystectomy.

OBJECTIVE: This study was aimed at evaluating and comparing the quality of life in patients who underwent laparoscopic and open cholecystectomy for chronic cholecystolithiasis. METHODS: The study included 25 patients with laparoscopic cholecystectomy (LC group) and 26 with open cholecystectomy (OC group). The quality of life was measured with the Gastrointestinal Quality of Life Index (GLQI) preoperatively, thereafter regularly at 2, 5, 10 and 16 weeks after the operation. RESULTS: The mean preoperative overall GLQI scores were 112.5 and 110.3 in LC and OC group respectively (P>0.05). In the LC group, the mean overall GLQI score reduced slightly to 110.0 two weeks after the operation (P>0.05). The LC group showed significant improvement in overall score and in the aspects of symptomatology, emotional and physiological status from 5 to 16 weeks postoperatively. In the OC group, the GLQI score reduced to 102.0 two weeks after surgery (P<0.05). Significant reductions were shown in the aspects of symptomatology, physiological and social status. The GLQI scores returned to the preoperative level of 115.6 ten weeks after the operation (P>0.05). The patients experienced significant improvements of GLQI sixteen weeks after OC operation (P<0.01~0.05). Within the 10 postoperative weeks, the LC group had significantly higher GLQI scores than the OC group (P<0.05). CONCLUSIONS: LC can improve the quality of life postoperatively better and more rapidly than OC. The assessment of quality of life assessment is a valid method for measuring the effects of surgical treatment.

Gallbladder rupture during laparoscopic cholecystectomy: does it have an effect on postoperative morbidity?

Gallbladder rupture during laparoscopic cholecystectomy is a common event that may lead to increased postoperative morbidity. To evaluate this event, we reviewed 300 cases of laparoscopic cholecystectomy. Duration of surgery and hospitalization, postoperative symptoms, wound infection, and late complications were analyzed by comparing two groups of patients, one without gallbladder rupture (A) and one with rupture (B). Gallbladder rupture was found in 40 cases (13.9%). Duration of surgery averaged 81 min for group A and 96.5 min for group B. Postoperative symptoms in the first 24 hours were present in approximately 10% of patients in both groups. Within the first 24 hours, 92.3% of patients in group A were discharged compared with 85% in group B. One patient (0.4%) in group A developed wound infection compared with 2 patients (5%) in group B (p = 0.05). To date, no patients have developed late abdominal complications associated with the procedure. Although this was a retrospective and uncontrolled study, gallbladder rupture during laparoscopic cholecystectomy was found to be associated with increased wound infections. No other significant effects on postoperative morbidity were detected.

Complications of cholecystectomy in the era of laparoscopic surgery.

Both open and laparoscopic cholecystectomy are highly safe and effective procedures for patients with symptomatic cholelithiasis. Today, adverse outcomes after open cholecystectomy are limited to the elderly patients with comorbid conditions and complicated biliary tract disease. Though underreported, major biliary tract complications still occur, more so with laparoscopic cholecystectomy and continue to be the main cause of morbidity after cholecystectomy.

Post-cholecystectomy biliary pain and dyspepsia (response to 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors).

BACKGROUND: The so called post-cholecystectomy syndrome is common, intractable, often progressive, causes prolonged suffering, and has no approved treatment. It usually presents with episodic biliary pains (colics), and postprandial dyspepsia (bloating and indigestion). Because treating a very recalcitrant case with lovastatin provided prolonged remission, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors were given to 12 subsequent patients with similar symptoms. OBJECTIVE: To determine whether HMG-CoA reductase inhibitors are useful in the therapy of post-cholecystectomy biliary pain and dyspepsia. METHODS: Open clinical trial in an internal medicine, private practice setting; data were collected from the patients' charts and from telephone interviews, five years after the index case had been treated. RESULTS: Eight of 12 patients experienced total resolution of their symptoms after many years of suffering; response occurred slowly within the first three months of treatment. Two other patients responded, stopped their medications, relapsed, and continue to be symptomatic. One patient did not take her medication and remains symptomatic; one other patient did not respond, was diagnosed with carcinoma of the pancreas, and died from it. CONCLUSIONS: These preliminary results suggest that HMG-CoA reductase inhibitors may be useful in relieving the symptoms of this common and intractable disorder. Controlled studies are needed.

[The surgical risk of laparoscopic cholecystectomy]. / Rischio operatorio della colecistectomia laparoscopica.

Laparoscopic cholecystectomy has become the treatment of choice for gallbladder stones. As a matter of fact, the advantages related to the significant reduction of postoperative pain and the early mobilization of the patient, with a decrease of general surgical risk, have been well demonstrated. Also the complications of the surgical wound have been drastically reduced. On the contrary, iatrogenic trocar-related injuries represent specific complications of laparoscopic technique. However, the incidence of these complications, mostly the more severe ones, may be significantly reduced with routine use of the "open" technique. The increased incidence of common bile duct (CBD) injuries in laparoscopic cholecystectomy compared with the conventional technique may be partly explained with the learning curve related to the rapid diffusion of this new approach. An appropriate training, a meticulous operative technique and an early conversion to open procedure in case of intraoperative difficulties may reduce the risk of a CBD injury. In this work the authors' experience of 400 laparoscopic cholecystectomies without CBD injury and major complications is presented. Conversion rate was 5.2% in patients with simple symptomatic cholelithiasis and 37.5% in patients with acute or subacute cholecystitis.

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

Introducción. 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 método. 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. Conclusión. 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

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

Postcholecystectomy syndrome (PCS).

The term postcholecystectomy syndrome (PCS) comprises a heterogeneous group of symptoms and findings in patients who have previously undergone cholecystectomy. Although rare, these patients may present with abdominal pain, jaundice or dyspeptic symptoms. Many of these complaints can be attributed to complications including bile duct injury, biliary leak, biliary fistula and retained bile duct stones. Late sequelae include recurrent bile duct stones and bile duct strictures. With the number of cholecystectomies being performed increasing in the laparoscopic era the number of patients presenting with PCS is also likely to increase. We briefly explore the syndrome and its main aetiological theories.

From acute to chronic pain after laparoscopic cholecystectomy: a prospective follow-up analysis.

OBJECTIVE: The pathogenesis and risk of chronic pain after cholecystectomy are unknown. In this prospective study of 150 consecutive patients undergoing laparoscopic cholecystectomy, the preoperative clinical data, cold pressor test, state of neuroticism and early postoperative pain intensity were assessed. MATERIAL AND METHODS: Follow-up questionnaires were sent to all patients 1 year after surgery. Patients with moderate/severe chronic pain were interviewed and invited to participate in a structured examination programme. RESULTS: The questionnaire response rate was 100%. Twenty patients reported moderate or severe chronic pain. The 1-year in-office interview revealed that two patients without chronic pain had misinterpreted the questionnaire. Sixteen patients were enrolled for the examination programme. Demonstrable pathology explained the aetiology of chronic pain in 8 patients (5%); another 8 patients with moderate (n=6) or severe (n=2) chronic pain were without pathological findings. In total, 132 patients had no chronic pain. Chronic pain patients suffered significantly more intense acute postoperative pain compared with those without chronic pain (p < or =0.05). The incidence of chronic pain patients was higher in the group of patients with intense acute postoperative pain than in patients with low acute postoperative pain (p = 0.030-0.063). Development of chronic pain was not statistically related to a preoperative cold pressor nociceptive stimulus, preoperative state of neuroticism or to any other variables examined. CONCLUSIONS: The risk of significant chronic pain after laparoscopic cholecystectomy for symptomatic cholecystolithiasis is low but was significantly associated with the intensity of acute postoperative pain. Patients should be carefully examined to exclude somatic causes of chronic pain after laparoscopic cholecystectomy.

Sump syndrome: endoscopic treatment and late recurrence.

OBJECTIVE: Biliary sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by food, stones, or debris after choledochoenterostomy. Endoscopic sphincterotomy has been recommended as the primary and definitive treatment modality. The aim of our study was to confirm the short and long term therapeutic efficacy of endoscopic treatment in a long follow-up period. METHODS: The series include 31 patients with characteristic clinical illness after choledochoduodenostomy. All of them were successfully treated by endoscopic sphincterotomy and bile duct clearance with a balloon catheter or basket. The follow-up period ranged from 18 to 84 months (median: 51 months). RESULTS: Clinical improvement was immediate in all patients. No complications were recorded. Recurrence of the syndrome, with restenosis of the sphincterotomy opening, was observed in six patients (19%) and was treated successfully and safely with a new papillotomy. Sump syndrome recurrence occurred 31-72 months (median: 58.5 months) after the initial treatment. CONCLUSIONS: We report a considerably high recurrence rate of sump syndrome after initially successful endoscopic management and its effective endoscopic treatment with a new papillotomy. We still believe that the primary therapeutic approach in patients with sump syndrome should be endoscopic.

[Results of cholecystectomy realized 10 years ago]. / Resultados de la colecistectomía a 10 años plazo.

BACKGROUND: The "post cholecystectomy" syndrome comprises a series of vague symptoms referred by patients subjected to this surgical procedure. These symptoms are unspecific and their association with the operation is dubious. AIM: To assess the frequency of digestive symptoms among patients subjected to a cholecystectomy ten years ago. PATIENTS AND METHODS: One hundred patients subjected to a cholecystectomy between 1987 and 1990, were contacted by mail. They were invited to a clinical interview and to an abdominal ultrasound examination. RESULTS: Two invited patients had died of an acute myocardial infarction. Therefore, 98 patients (78 women), aged 30 to 85 years old, were assessed. Seventy two percent had diverse dyspeptic symptoms, 90% had no food intolerance and 94% had gained weight after the operation. Ninety six percent was satisfied with the surgical results, 3% had severe symptoms due to gastroesophageal reflux or depression. One patient had a residual choledocholithiasis and refused any treatment. CONCLUSIONS: Cholecystectomy is well tolerated and has good long term results.

Systemic immune response after laparoscopic and open cholecystectomy.

The laparoscopic approach is thought to reduce the postoperative immunologic and metabolic effects of an open operation. This study was designed with the aim of comparing the systemic immune response after laparoscopic and open cholecystectomy. Seventeen patients with gallbladder stones were assigned to undergo either a laparoscopic (n = 9) or open (n = 8) approach. The postoperative immune response was assessed by measuring the serum levels of soluble Fas (sFas), soluble L-selectin (sL-selectin), and transforming growth factor-beta1 (TGFbeta1) preoperatively and 2 hours, 1 day, and 2 days postoperatively. Both approaches resulted in a significant decrease in sFas levels 1 and 2 days postoperatively. The open approach evoked a transient increase in sL-selectin levels 2 hours postoperatively. Moreover, the open approach resulted in a persistent, significant increase in TGFbeta1 levels postoperatively. Comparison of open versus laparoscopic cholecystectomy has shown no significant difference in sFas level and a statistically significant increase of sL-selectin (within 2 hours) and TGFbeta levels after open surgery. Although both laparoscopic and open cholecystectomy evoked an alteration of the systemic immune response, our data showed that such immune response may be less after the laparoscopic approach.

[Gallbladder calculi--always an indication for surgery?]. / Gallenblasensteinleiden-immer eine Operationsindikation?

There is consensus that symptomatic cholecystolithiasis presents an indication for cholecystectomy. Today the surgical method of choice is the laparoscopic technique, which has proven its superiority in numerous randomized studies. Epidemiologic studies showed that 10-15% of all gallstone patients develop complications so that a prophylactic cholecystectomy is repeatedly being discussed. A few older studies based on conventional cholecystectomies, however, showed no decisive advantage for a prophylactic cholecystectomy, but rather clearly higher costs. Therefore a wait-and-see policy is generally recommended for asymptomatic gallstones. The analysis of our large group of patients showed that acute cholecystitis as well as common bile duct stones occur significantly more often with increasing duration of the gallstone disease. The older the patient, the longer the operation time, the more frequent a conversion, and the higher the morbidity of the procedure. Considering the minor impairment of daily activities with the laparoscopic technique, the present concept of treatment for asymptomatic and mildly symptomatic cholecystolithiasis needs to be scrutinized.

Biliary ascariasis as a cause of post-cholecystectomy syndrome in an endemic area.

BACKGROUND: Post-cholecystectomy syndrome encompasses numerous biliary, pancreatic and other entities. Biliary ascariasis is a common cause of adult biliary disease in an endemic area. Post-cholecystectomy biliary ascariasis, a cause of post- cholecystectomy syndrome although not yet defined is frequently seen in this part of the world. METHOD: Between Jan. 1990 and Jan. 2001, 104 cases of post-cholecystectomy biliary ascariasis were seen. Ultrasonography was found to be an excellent tool for diagnosing and monitoring of the worms inside the biliary tract. Endoscopic retrograde cholangiopancreatography had both diagnostic and therapeutic value. RESULTS: The majority (68.2%) of patients responded to conservative treatment. Surgical treatment was advocated in 18.2%, which included 2 patients with liver abscesses. Endoscopic extraction of worms was successful in 48.2%. CONCLUSION: Post-cholecystectomy biliary ascariasis as a cause of post-cholecystectomy syndrome needs to be included in the list of causes for post-cholecystectomy syndrome. Although the majority of patients respond to conservative treatment but endoscopic extraction or surgical intervention may be needed. Routine deworming of patients undergoing cholecystectomy both preoperatively and postoperatively should be done in all patients in endemic areas of ascariasis. Although this entity is rare in Europe and United States, due to population migration and increased travel, it is necessary for surgeons in these countries to be aware of this condition.

Relation of coffee, green tea, and caffeine intake to gallstone disease in middle-aged Japanese men.

A possible protective effect of coffee or caffeine intake in the formation of gallstones has been suggested in some epidemiological studies. We examined the relation of coffee, green tea, and caffeine intake to gallstone disease in middle-aged Japanese men, distinguishing known gallstones from unknown diagnosed gallstones. Study subjects were 174 cases of gallstones as determined by ultrasonography, 104 cases of postcholecystectomy, and 6889 controls of normal gallbladder in the total of 7637 men who received a health examination at four hospitals of the Self-Defense Forces (SDF). Of the 174 cases of prevalent gallstones, 50 had been aware of having gallstones. Previously diagnosed gallstones and postcholecystectomy were combined as known gallstone disease. The consumption of coffee and green tea was ascertained by a self-administered questionnaire, and caffeine intake was estimated. Statistical adjustment was done for body mass index, smoking, alcohol use, rank in the SDF, and hospital. Coffee and caffeine intake were associated each with a statistically significant increase in the prevalence odds of known gallstone disease, but unrelated to newly diagnosed gallstones. Adjusted odds ratios of known gallstone disease were 1.7 (95% confidence interval [CI] 1.1-2.8) for coffee consumption of five cups or more per day vs. no consumption and 2.2 (95% CI: 1.3-3.7) for caffeine intake of 300 mg/day or more vs. less than 100 mg/day. The consumption of green-tea showed no material association with either unknown gallstones or known gallstone disease. The findings do not support a hypothesis that coffee drinking may be protective against gallstone formation.