A systematic review of the aetiology and management of post cholecystectomy syndrome
Introduction
Symptoms attributable to gallstone disease result in 60,000 cholecystectomies per annum in the UK.1 Improvements in surgical techniques and advances in post-operative care have resulted in just over 50% of cholecystectomies being performed as day-cases, a rise from 16% in 2008–09.2, 3 The majority of patients recover uneventfully. 10% of patients may develop post-cholecystectomy syndrome (PCS) weeks to month's later.4
Post cholecystectomy syndrome was first described in 1947 by Womack and Crider.5 It refers to the persistence of gastrointestinal symptoms following cholecystectomy and may occur in 5–47% of patients.6, 7, 8 The aetiology can be broadly divided into biliary, extra-biliary, organic and functional.9
It has been hypothesised that the majority of patients who develop post cholecystectomy syndrome may actually suffer from extra-biliary or organic disorders, such as gastroesophageal reflux disease or acute and chronic pancreatitis.10 The difficulty lies in establishing whether these disorders were present before cholecystectomy and were subsequently exacerbated by the post-operative changes in biliary kinetics, or whether they are new symptoms secondary to the procedure. Inappropriate operations may also predispose to the development of PCS.
Retained stones, de novo ductal stone formation, strictures and sphincter of Oddi dysfunction (SOD) may all present as PCS and can all be attributed to biliary aetiology post-surgery.11 The Rome III committee concluded that PCS pain could be categorized by character and location of symptoms,12 and thus assist characterisation.
Due to the different causes of PCS there are a number of management options available. These can be categorized into medical, endoscopic and surgical. The management of choice is largely dependent on the aetiology and premorbid state of the patient. Although guidelines exist for the management of the underlying cause of post cholecystectomy syndrome e.g. retained or de novo stone, there are no published guidelines on how to investigate post cholecystectomy syndrome of unknown cause for the underlying aetiology.
This systematic review aims to describe the causative aetiologies of post-cholecystectomy syndrome. Their incidence, therapeutic interventions, patient outcomes, resolution of symptoms and adverse are also described.
Section snippets
Materials and methods
This systematic review was registered with the PROSPERO database of systematic reviews (CRD42016035916) and reported in accordance with the PRISMA guidelines.53
A systematic search of Medline, Embase and Cochrane databases was conducted. The search strategy comprised the keywords and MeSH terms: ‘Post Cholecystectomy Syndrome’, ‘aetiology’ and ‘management’ for the time period 1990–2016. Search strategies for each database are included in the supplement. The inclusion criteria were as follows;
Results
The search identified 1077 articles (Fig. 1). Duplicate articles were removed, 104, and the remaining titles and abstracts were reviewed. 876 articles were excluded following title and abstract screen and 97 potentially eligible references were identified for full paper review. On full text review, 69 were excluded and we were unable to obtain the full paper for 7 references by inter library loan despite a national search, leaving 21 articles for data extraction (15 case series, 2 cohort
Discussion
This systematic review collates the findings of nearly three decades of research on PCS. A key finding of this review is the spectrum of aetiologies that contribute to PCS. In the first three years post cholecystectomy the most frequent diagnoses are peptic ulcer disease, GORD and hiatal hernias. Beyond three years, the most common diagnoses relate to ductal stones and microlithiasis although nearly a third of cases will not have a conclusive diagnosis. The frequency of SOD is low, accounting
Conclusion
Post cholecystectomy syndrome is used to describe a collection of symptoms experienced by patients following cholecystectomy, many of which can be attributed to causes beyond the biliary system. The symptoms experienced are not collectively representative of a single disease or abnormality so referencing them as a syndrome may be inaccurate. Whether some of the symptoms are truly a result of gallbladder removal is questionable. In the immediate period following laparoscopic cholecystectomy many
Author contributions
Miss Isherwood and Mr Khanna designed the hypothesis.
All authors were involved in review of abstracts and full papers, as an independent reviewer or arbitrator.
Miss Isherwood and Miss Oakland extracted and interpreted the data.
Miss Isherwood drafted the manuscript and Miss Oakland and Mr Khanna provided critical revisions.
Disclosures
The authors have no conflicts of interest or financial ties to disclose.
Ethical approval statement
For this type of study formal consent is not required.
Informed consent statement
Does not apply.
Acknowledgements
The Authors have no acknowledgements to make.
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2021, Surgical Clinics of North AmericaCitation Excerpt :As this is a rare complication, conversion to open is not generally not recommended for retrieval of stones. Postcholecystectomy syndrome (PCS) describes the persistence or development of new gastrointestinal symptoms after cholecystectomy, and has been estimated to occur in anywhere from 4% to 18% of patients.109,110 Symptoms can include abdominal pain, indigestion, fatty food intolerance, heartburn, vomiting, and diarrhea.