bubble_chart Overview

Postcholecystectomy Syndrome (PCS), also known as post-cholecystectomy sequelae or Recurrent Biliary Tract Syndrome, refers to a clinical syndrome related to biliary tract disorders that occurs after gallbladder removal. It is generally believed that about 25-30% of patients may experience transient symptoms after cholecystectomy, which usually resolve quickly. However, approximately 2-8% of patients may require active treatment due to persistent symptoms.

bubble_chart Etiology

The occurrence of this disease after cholecystectomy may be related to the following factors:

1. Intraoperative injury to the bile duct. Due to significant anatomical variations between the gallbladder and the extrahepatic bile ducts, or the surgeon's lack of experience, the extrahepatic bile ducts may be injured during surgery, leading to postoperative bile duct stenosis. A minority of cases may result from postoperative peribiliary infections, causing bile duct damage or obliterative cholangitis.

2. Stenosis of the Oddi sphincter and constrictive papillitis of Vater. The reasons for these pathological changes postoperatively are unclear but may be associated with concurrent common bile duct stones, particularly bilirubin sludge stones, or local chronic inflammatory edema.

3. Postoperative abnormalities in bile salt metabolism and autonomic nervous system dysfunction may affect the excretion of bile, the tonicity of the Oddi sphincter, and the pressure in the common bile duct, potentially playing a role in the occurrence of this disease.

The possible causes of the disease include: ①Dysfunction of the Oddi sphincter, accounting for approximately 2.4% of post-biliary surgery issues. Currently, there is no reliable diagnostic method for this condition. ②Preoperative misdiagnosis of conditions that remain undetected and untreated, such as hiatal hernia, colonic dysfunction, irritable small intestine syndrome, peptic ulcer, etc., which require relevant examinations for confirmation. ③Many authors believe that psychological factors may be involved but do not require intervention.

bubble_chart Pathogenesis

1. Biliary tract diseases causing

Post-cholecystectomy syndrome caused by biliary tract diseases, such as extrahepatic or intrahepatic bile duct stones, Oddi sphincter stenosis, etc. It can also be caused by the cholecystectomy itself, such as an excessively long remnant cystic duct or traumatic bile duct stenosis.

1. Bile duct stones: The most common cause of post-cholecystectomy syndrome. They can be classified as residual stones or recurrent stones, with reported incidence rates ranging from 5% to 75%, or even as high as 87.8%.

(1) Residual stones: Stones not completely removed during surgery, which can be further divided into: ① Avoidable residual stones: Often caused by inadequate intraoperative exploration or lack of technical proficiency. ② Unavoidable residual stones: Intraoperative exploration reveals intrahepatic bile duct stones, but technical difficulties or critical patient condition prevent thorough exploration or stone removal.

(2) Recurrent stones: Stones that reappear after complete removal during surgery, making them difficult to identify. Some suggest that symptoms appearing more than two years post-surgery can be classified as recurrent stones.

2. Post-injury bile duct stenosis: Also known as traumatic bile duct stenosis or postoperative bile duct stenosis. Over 95% of cases occur after cholecystectomy, with an incidence rate of approximately 0.1%–0.2%, meaning one case of bile duct injury-induced stenosis occurs per 100–200 cholecystectomies. Post-injury bile leakage leads to bile peritonitis, and even after healing, fibrotic stenosis persists, causing poor bile drainage and recurrent cholangitis. Stenosis, infection, and recurrent stones form a vicious cycle.

3. Excessively long remnant cystic duct: A remnant cystic duct longer than 1 cm after cholecystectomy is considered excessively long. In an X-ray analysis of 132 patients with post-biliary surgery syndrome, 20 cases (15.2%) showed a visible remnant cystic duct. This is often due to the surgeon’s inexperience, surgery during acute inflammation, anatomical anomalies, or severe adhesions around the gallbladder neck. While usually asymptomatic, if stones are present in the remnant cystic duct or there is distal bile duct obstruction, poor bile drainage and increased pressure can lead to dilation and secondary infection, forming an inflamed "mini-gallbladder." Main symptoms include abdominal pain and fever, with jaundice in rare cases. Other symptoms include dyspepsia, anorexia, abdominal distension and fullness, nausea, and vomiting. During cholecystectomy, attention must be paid to the cystic duct. If the common bile duct is not dilated, stone-free, and not explored, cutting and ligating the cystic duct 0.5 cm from the common bile duct is reasonable. For dilated or stone-containing common bile ducts, routine exploration should include checking the cystic duct opening for stones, and the cystic duct should be ligated as close to the common bile duct as possible to minimize remnant length. This approach avoids common bile duct injury and prevents excessive remnant length.

4. Post-biliary surgery functional disorders: More common in young women, often triggered by psychological factors or endocrine dysfunction. Symptoms include paroxysmal right upper abdominal pain, accompanied by abdominal distension and fullness, profuse sweating, and tachycardia, but without signs of infection. X-ray or ultrasound findings are negative.

Sugawa’s ERCP study of post-cholecystectomy syndrome found positive findings in 73% of cases, while 27% showed no abnormalities, primarily due to biliary dysfunction. Bar-meirs identified sphincter dysfunction in 2 of 15 cases (14%) via ERCP manometry, with bile duct pressure changes and Oddi sphincter spasm causing common bile duct dilation. Tanaka suggested that after cholecystectomy, the bile duct loses its pressure-buffering function, becoming directly influenced by sphincter activity. Sphincter contraction significantly increases bile duct pressure in post-cholecystectomy patients. Bardley and Collins proposed that elevated serum cholecystokinin levels post-cholecystectomy can induce Oddi sphincter contraction, leading to symptoms when biliary pressure rises.

2. Non-biliary diseases causing

Some of the patient's symptoms existed before the cholecystectomy, and the gallbladder disease masked these symptoms. During the cholecystectomy, accompanying conditions such as hiatal hernia, ulcer disease, chronic pancreatitis, chronic hepatitis, etc., were overlooked. After the cholecystectomy, the symptoms of gallbladder disease disappeared, and the symptoms of extra-biliary diseases became apparent.

bubble_chart Clinical Manifestations

Symptoms typically appear weeks or months after cholecystectomy, primarily manifesting as discomfort or pain in the upper abdomen or right hypochondrium, often presenting as dull or persistent pain, or a sense of pressure. This differs in nature from the pre-operative biliary colicky pain. It may be accompanied by loss of appetite, nausea, abdominal distension, and fullness. Occasionally, biliary spasms can lead to episodes of colicky pain. The symptoms are often related to eating, especially fatty foods. In severe cases, infection of the biliary tract may spread upward, resulting in chills, high fever, and jaundice.

bubble_chart Auxiliary Examination

1. Generation and transformation examination: White blood cell count, hematuria, amylase, liver function, alanine aminotransferase, γ-glutamyl transpeptidase, etc., are very helpful for the diagnosis of biliary obstruction.

2. Intravenous cholangiography: The visualization of intrahepatic bile ducts is poor, and the extrahepatic bile ducts are also unclear. It is greatly affected by liver function, so its diagnostic value is limited.

3. B-mode ultrasound: Can detect bile duct dilation, gallstones, biliary tract tumors, pancreatitis, etc. It is simple, rapid, and has certain diagnostic value, but it has limitations and cannot display the entire biliary system or all pathological signs.

4. Upper consumptive thirst digestive tract radiography: Very helpful in diagnosing hiatal hernia, ulcer disease, duodenal diverticula, etc.

5. Hepatobiliary CT scan: Used to diagnose liver tumors, intra- and extrahepatic bile duct dilation, gallbladder stones, chronic pancreatitis, etc.

6. Isotope ^99mTc-HIDA hepatobiliary scan: Observes intra- and extrahepatic bile duct dilation, gallbladder stones, liver lesions, and gallbladder function. The method is simple, non-invasive, and suitable for jaundice patients.

7. Endoscopy: Includes esophagoscopy, gastroscopy, duodenoscopy, etc.

ERCP has definitive diagnostic value for post-cholecystectomy syndrome. Hu Jiayou et al. reported findings and experiences from 181 cases of ERCP for diagnosing post-biliary surgery syndrome. The diseases identified were as follows: Causes could be determined in 169 cases (93.4%), including biliary stones in 159 cases (87.8%), biliary strictures in 73 cases (40.3%), biliary dilation in 106 cases (58.6%), and chronic recurrent cholangitis in 90 cases (49.7%). The cause was unknown in 12 cases (6.6%). The diagnostic success rate of ERCP was 83.3%, as it can directly, accurately, and clearly display the entire biliary system and lesions, including their morphology, size, location, and quantity.

8. PTC: This direct cholangiography method is suitable for differentiating severe jaundice and locating biliary lesions.

9. Morphine-neostigmine provocation test: The method involves intramuscular injection of 10 mg morphine and 1 mg neostigmine. Blood is drawn before injection and at 1, 2, and 4 hours after injection to measure serum amylase and lipase. The test is positive if upper abdominal pain occurs after injection and serum enzyme levels exceed three times the normal value.

bubble_chart Diagnosis

Based on medical history (history of gallbladder, bile duct, or stomach and duodenum surgery), postoperative fever, abdominal pain, and jaundice, the possibility of postoperative bile duct stones or bile duct stricture should be considered. B-ultrasound, CT, endoscopy, and cholangiography can aid in diagnosis; examinations such as ERCP or PTC, combined with fine-needle puncture (FNPTC) when necessary, can provide satisfactory diagnostic results. For suspected Oddi sphincter stenosis or dysfunction, a morphine-neostigmine provocation test can be performed. Even after ERCP and FNPTC examinations, a small number of patients may still have unclear causes and pose diagnostic challenges.

bubble_chart Treatment Measures

The treatment objectives of PCS are to eliminate the disease cause, ensure unobstructed biliary drainage, and control infection. Mere "symptomatic treatment" often fails to yield satisfactory results. Therefore, it is essential to further investigate the underlying causes and establish a clear diagnosis before treatment. Treatment methods include non-surgical and surgical therapies.

I. Non-surgical Therapy

1. Indications ① Bile duct stones with a diameter <1 cm and no stricture at the lower end of the bile duct. ② Biliary tract infection without significant bile duct obstruction. ③ Acute or chronic cholecystitis, pancreatitis. ④ Biliary ascariasis. ⑤ Biliary dysfunction. ⑥ Extra-biliary diseases such as hiatal hernia, peptic ulcer, chronic pancreatitis, etc.

2. Treatment Methods ① General therapy: Includes dietary therapeutics, fluid infusion, and correction of typical edema, electrolyte, and acid-base imbalances. ② Chinese medicine and Chinese medicinals: Traditional Chinese medicine and herbal treatments based on pattern identification have shown good efficacy for gallbladder and bile duct stones, biliary tract infections, pancreatitis, biliary ascariasis, and other conditions. - For hypochondriac pain, pallor, and wiry pulse due to liver qi stagnation: Modified Bupleurum Liver-Soothing Powder. - For hypochondriac pain, chills, fever, bitter taste in the mouth, dry throat, jaundice, red tongue with yellow greasy coating, and slippery rapid pulse due to internal dampness-heat: Major Bupleurum Decoction combined with Virgate Wormwood Decoction. - For hypochondriac pain, high fever, dry mouth, jaundice, yellow tongue coating, and wiry rapid pulse due to intense fire toxin: Coptis Detoxification Decoction plus Virgate Wormwood Decoction. Additionally, for pancreatitis, Qingyi Decoction (comprising Bupleurum, Aucklandia Root, Corydalis Tuber, Peony Root, Skullcap Root, Rhubarb Rhizoma, Mirabilite, etc.) is primarily used. For biliary ascariasis, Smoked Plum Decoction may be added. ③ Acupuncture: Used for pain relief and regulation of biliary function. ④ Others: Antibiotics, antispasmodics, analgesics, antacids, H₂-receptor blockers, etc.

II. Surgical Therapy

1. Indications ① Recurrent large bile duct stones, intrahepatic bile duct stones, impacted ampullary stones, or bile duct strictures combined with stones. ② Bile duct strictures with recurrent biliary infections or obstructive suppurative cholangitis. ③ Oddi’s sphincter stenosis, chronic pancreatitis with ampullary or pancreatic duct obstruction. ④ Excessively long remnant cystic duct forming an inflamed small gallbladder. ⑤ Extra-biliary diseases refractory to medication, such as hiatal hernia or peptic ulcer.

2. Surgical Methods The surgical approach depends on the specific condition: ① For a long remnant gallbladder or cystic duct: Cholecystectomy or cystic duct resection. ② For bile duct stones: Common bile duct exploration, stone removal, and various biliary-enteric anastomoses or endoscopic sphincterotomy and stone extraction. ③ For Oddi’s sphincter stenosis: Sphincteroplasty. ④ For bile duct strictures: Common bile duct plasty and repair or biliary-digestive tract reconstruction, such as choledochoduodenostomy, Roux-en-Y hepaticojejunostomy, or Longmire procedure. ⑤ For severe extra-biliary diseases like hiatal hernia or peptic ulcer: Corresponding medical or surgical treatment should be administered.

bubble_chart Prevention

Most cases of postcholecystectomy syndrome can be prevented and cured early.

1. Actively promote integrated traditional Chinese and Western medicine in treating biliary diseases, strictly follow surgical indications, minimize emergency biliary surgeries as much as possible, and select appropriate surgical approaches.

2. Popularize biliary imaging diagnostic methods to fully understand biliary pathological changes. Biliary tract imaging, choledochoscopy, and biliary pressure measurement can help improve the therapeutic outcomes of biliary surgeries.

3. Intrahepatic bile duct lesions are relatively rare in China, and the surgical difficulty is high, making it crucial to enhance biliary surgical techniques. If various biliary surgeries can eliminate the disease cause, prevent biliary strictures, and establish unobstructed drainage, the occurrence of post-biliary surgery syndrome will undoubtedly decrease.