Late choledochal pathology after cholecystectomy for cholelitiasis
E. Brãtucu, D. Straja, M. Marincas, C. Daha, C. Cirimbei, C. BoruArticole originale, no. 3, 2006
* Department of General and Digestive Surgery, Universitary Hospital Caritas, Bucharest, Romania
* Department of General and Digestive Surgery
* Department of General and Digestive Surgery
Introduction
Regarding long-term follow-up after gallbladder removal, our interest was focused on postcholecystectomy syndrome, widely described s1-9t, both after open and laparoscopic surgery s10t. Two types of pathology have been described: organic (26-30%) and functional (70%). This kind of pathology appears in most of the cases in the first 12 postoperative months s3, 8t, specially first 30 days s11t, but can recur even years after cholecystectomy s12-14t. After "simple" cholecystectomy for lithiasis, billiary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. Meantime, a whole range of congenital abnormalities initially ignored can become manifest: billiary tract congenital dilatations, duodenal para-Vater diverticulum, Oddian stenosis. Konsten et al s6t studied 325 patients with cholecystectomy, evaluating ten years postoperative pathology. They found that 18.5% of patients had complaints after cholecystectomy. Marotta et al s7t, followed-up 41 patients with postcholecystectomy syndrome, and found only 36.8% of them asymptomatic, while 34% of them had choledocholithiasis, 9.8% benign choledochal stenosis, 4.9% chronic pancreatitis and rest of them other pathology. Rolny et al s15t identified 17 patients with sphincter of Oddi dysfunctions after mean interval of 18 years postcholecystectomy and showed that endoscopic retrograde cholangiopancreatography (ERCP) is a better diagnosis procedure compared with endoscopic billiary manometry. Finally, Jensen et al s16t and Zhou at al s17t, studying thoroughly the same syndrome, recommended (ERCP) as the best diagnosis procedure, followed by therapeutic measure according to the clinical practice. In the absence of ERCP suggestive findings for organic lesions, endoscopic billiary manometry is needed, also quantitative choledochoscintigraphy, spiral CT or RMN cholangiopancreatography s18, 19t.
The aim of our study was to establish the pathological circumstances that determine late choledochal syndrome, including an analysis concerning the therapeutical approach in these cases.
Patients and methods
Our retrospective study analyzes a group of patients treated in the Surgical Department of University Caritas Hospital "Acad. N. Cajal" Bucharest between 1997 and 2005. Patients previously underwent simple cholecystectomy for lithiasis (open surgery or laparoscopy) in our department or in other surgical departments, and complained of late billiary disorders after 3 years of postoperative asymptomatic period.
In this period, 2487 cholecistectomies, 262 in open surgery and 2225 in laparoscopy (89%) were performed in our department. Meanwhile, 450 endoscopic billiary procedures: 129 diagnostic endoscopic retrograde cholangiopancreatography (ERCP) and 277 ERCP combined with endoscopic sphyncterotomy (ES) were performed. 44 ERCP failures were registered. Intraoperative cholangiography was not performed routinely, but only in selective cases, when indication was established on clinical, laboratory, ultrasonography (US) examination and intraoperative criteria.
The asymptomatic period of at least three years after cholecystectomy years was arbitrarily chosen. This period is usually used in estimation of long-term follow-up results after therapeutically procedures, justifying our option for this period, also after cholecystectomy.
Exclusion criteria of the study were: early difficult post-operative course, with early complications such as retained common bile duct (CBD) stones, angiocholitis, billiary fistulas, etc; incomplete surgical procedure, recognized or accordingly specified: retained CBD stones, incomplete cholecystectomy; intraoperative incidents or accidents noted in operation charts: billiary tract injuries, vascular injuries, etc.
Therapeutical approach was endoscopical (ERCP, diagnostic or combined with ES), surgical or conservative.
Results
Forty-six patients entered the study group, from which 38 previously underwent open cholecystectomy. Seven patients had undergone cholecistectomy in our surgical department, while others referred to our centre after initial operation in other centres. Late choledochal pathology became manifest after an average period of 10 years, ranging from 3 to even 30 years postcholecystectomy. Summing the asymptomatic postoperative periods for all 46 patients included in our trial resulted an amount of 320 years.
Patients were divided in 3 groups: group A - retained choledochal stones (10 patients), group B - primary choledocholitiasis (16 patients) and group C - non-lithiasis choledochal syndrome (20 patients). Etiopathological causes of late choledochal pathology found are reported in table 1.
56.5% of the patients were found with CBD lithiasis, especially primary type (61.5%). Most frequent cause of admission for billiary desobstruction was choledocolithiasis. 41.3% of our patients presented combined causes of late choledochal syndrome.
Therapeutical approach was endoscopic in 38 cases, from which 8 cases failed; 5 patients benefited of conservative treatment after diagnostic ERCP. ERCP combined with ES was successfully applied in 65.2% of our patients. Open surgery was used in 10 cases (21.7%), 2 cases as first choice and 8 after failed endoscopic procedures. 1 patient refused any procedure.
The morbidity and mortality rates of our group were similarly with acceptable rates reported in the literature; however, we did not proposed to analyze these rates in this study.
Group A - Retained choledochal stones: 10 patients
An average asymptomatic period of 4.5 years after cholecystectomy is reported for this group. All patients presented obstructive jaundice. Three patients presented also lithiasic cystic stump, after incomplete cholecystectomy, but unrecorded as an incomplete procedure. The extracted stones were solid, with faceted aspect, suggesting migration, as in the next case:
Case 1: 48 years-old female, presented in 2005 (12 years postcholecystectomy) with right hypocondrial pain, jaundice syndrome, hyperbilirubinemy and inflammatory syndrome. ERCP showed CBD dilatation (30 mm) with papillary stone and segmentary CBD dilatation. ES was performed with stone extraction (fig.1, fig. 2).
We performed 3 open desobstructions, where endoscopic procedure failed. The other 7 patients benefited all of endoscopic treatment. Twelve ES for desobstruction were necessary, sometimes being obliged to enlarge the sphycterotomy in successive step procedures. The endoscopic approach was not complicated, with no need of open surgery.
Group B - Primary CBD stones 16 patients
Obstructive jaundice was registered in all patients. The interval between cholecystectomy and diagnosis of late choledochal complication averages 14 years with a maximum range 30 years. In only 9 cases (56.2%) we were able to identify a billiary flow obstruction, in order to explain stone formation: 3 inflammatory stenosis of Oddi sphincter, 3 CBD congenital dilatations and 3 duodenal para-Vater diverticulum. The analysis showed that just 9 cases of all 16 presented anatomical and functionally circumstances capable of altering billiary hydrodynamics. No evident pathological changes capable to explain the appearance of late CBD stones after cholecystectomy were identified in the other 7 patients. We present one of these cases, illustrated in fig. 3.
Case 2: 48 years-old female, 5 years postcholecystectomy, presented in our clinic with right hypocondrial pain, jaundice syndrome, hyperbilirubinemy, leucocytosis and transitory hepatic cytolysis. Preoperative US examination showed CBD dilatation (15-17mm) with distal choledochal stone. ERCP confirmed CBD lithiasis and ES was performed with stone extraction; good immediate postoperative evolution was registered, with total remission of complains.
The CBD stones identified in patients from group B had primary stones features: soft, browny, earthy in consistency, crumbly. Therapeutical approach was endoscopical in 10 cases and open surgery in other 6 cases. Overall we performed 20 ES, of which 10 were iterative sphyncterotomies, some of patients requiring 2 or 3 step by step procedures. Endoscopical failures were caused by CBD panlithiasis (2 patients) or the large size of stones (2 patients). Cystic dilation of CBD (2 cases) mandated open surgery with Roux-en Y hepaticojejunostomy.
In summary, in 26 cases from groups A and B (CBD stones, primary and residual), 32 ES were performed, 15 of them being iterative. Seven endoscopic desobstruction failures were registered, 3 retained and 4 primary CBD stones, in which open-surgery was required. In 2 cases the open surgery was the first choice, excluding the endoscopic approach.
Group C - non lithiasis CBD syndrome 20 patients
Clinical findings were upper abdominal pain, angiocholitis and jaundice syndrome caused by: a) Oddian stenosis in 9 cases, 3 of them occurred as recurrences after ES performed for postcholecystectomy syndrome manifested over 3 years postoperative; b) duodenal para-Vater diverticulum 8 cases; c) cholestatic hepatitis with sclerosing cholangitis 2 cases; d) congenital dilatation of billiary tract type I in 3 cases; e) gallbladder (cystic) stump lithiasis, without CBD lithiasis in 2 cases.
Plurifactorial etiology was observed in this group had; therefore each patient had many pathological circumstances. Clinical features were scarce, unlike in lithiasis CBD syndrome: clinical jaundice was found in just 7 cases. The main symptoms were upper abdominal pain, angiocholitis and jaundice being of low intensity and of short duration.
The mean period between cholecystectomy and late choledochal syndrome occurrence was 9 years. Treatment consisted in 14 ES, some of them being iterative: 9 required for oddian stenosis; 4 for a "tactical" or "safety" indication: in 2 cases cholestatic hepatitis and in 2 cases with gallbladder (cystic) stump lithiasis. One endoscopic desobstruction failure was registered caused by cystic stump lithiasis and open-surgery was required.
Case 3: 66 years-old female, presented in 2003 (3 years after cholecystectomy) with epigastric pain, angiocholitis, jaundice syndrome, hyperbilirubinemy, leucocytosis and hepatic cytolysis. Preoperative US showed large dilatation of CBD (22 mm) and intrahepatic billiary tree and also distal CBD stones. Endoscopic approach showed periampullary diverticulum, dilatation of cystic stump with an 18 mm stone, and moderate dilatation of CBD. ES was performed. Open surgery removed the stone from the cystic stump; explorative choledocotomy with cholangiography ended with Kehr drainage. Positive immediate postoperative evolution was registered (fig. 4, fig. 5).
One patient refused ES; therefore we abstained from any procedure. ES was first choice even in cases with congenital dilatation of billiary tract, without lithiasis, as it shows case further presented:
Case 4: 67 years-old female, presented in 2002 (29 years after cholecystectomy) with epigastric pain, jaundice syndrome, hyperbilirubinemy, leucocytosis and hepatic cytolysis. Preoperative US showed dilatation of CBD (14mm) with moderate dilatation of intrahepatic billiary tree. ERCP showed CBD dilatation (18 mm) with CBD diverticulum and long cystic stump retroduodenally inserted. ES was performed with good immediate postoperative evolution (fig. 6).
The other 5 patients from group C did not require endoscopical desobstruction or open surgery, conservative treatment being effective.
In summary, regarding the therapeutical management of entire study group, endoscopic treatment was possible in 30 patients (table 2). Thirty-six ES were performed, some of them iterative, choosing gradual sphyncterotomy for decreasing the rate of bleeding or obtaining a total desobstruction when first step was incomplete. In 8 cases, the endoscopic procedure failed: 3 cases with retained CBD stones, 4 cases with primary CBD lithiasis and 1 case with cystic stump lithiasis; one patient was uncompliant.
Discussions
We chose to analyse the late choledochal pathology because, unfortunately, it is found in all hepato-billiary surgical departments. Singh et al (19), published a study consist of patients with complains 7 years postcholecystectomy. Billiary pathology was found in 70% of cases. In other studies, Tulassay et al (21) and Coopermann et al s2t, found at the ERCP examination 56% and 52%, respective, late postoperative lesions. Starkov et al (22) revealed the presence of duodenal para-Vater diverticulum in 30% of the patients with postcholecystectomy syndrome. From 87 patients identified with para-Vater duodenal diverticulum, 47% had CBD lithiasis, 15% CBD stenosis and 10% Oddian stenosis. Therefore, para-Vater duodenal diverticulum represents one of the bases of billio-pancreatic pathology. Kim et al (23) also underline the high risk of recurrent CBD lithiasis in patients with para-Vater duodenal diverticulum.
The puzzling remark was that a group of patients with "simple" cholecystectomy, considered without doubted initially as therapeutically achievements, developed an unexpected and not negligible pathology, increasing the rate of late complications after billiary surgery, all this after proper surgical indication and technique, without intraoperative incidents or accidents. We found out that, even after a "simple" cholecistecomy, late complications, hard to explain, can occur: angiocholitis, jaundice syndrome, late CBD lithiasis, inflammatory stenosis, undiagnosed congenital dilatations of billiary tract, para-Vater duodenal diverticulum, etc. Some of this pathology, preceded cholecystectomy, but escaped detection. For elucidating this unclear pathology, we excluded patients with early difficult postoperative evolution.
We were trying to focus on silent complications started after three years postcholecystectomy. It is surprising to find out the long period of arising of primary CBD stones. It is possible that"late" term, from the title, could cause some misunderstanding. This interval was arbitrary chosen, but based on the evidence of possible late onset (12-14). We are dealing with a latent pathology, late manifested. Because we encountered such cases, even after so called "ordinary" billiary surgery, we approached this group of patients, in order to find the real reasons of this type of pathology.
Most of the cholecystectomies were done in open surgery (82.6%), due to general diffusion of the approach at the era. The "oldest" cholecystectomy from our group was done in 1965. We believe that in the future this rate will be inverted, meaning that type of pathology will be prevalent after laparoscopic approach. Billiary symptomatology after laparoscopic procedure is generally attributed to the longer cystic duct remnant, defined as a residual duct greater than 1 cm in length (12, 13).
From entire list of late choledochal pathology, only retained CBD stones suggests an incomplete surgical act, as might be appreciated as "faulty repair". It is not something unusual, because CBD retained stones are reported in the most significant statistics, even those where perioperative cholangiography is performed routinely. This early complication, extremely unpleasant for the surgeon, usually becomes manifested in the first 30-45 days after cholecystectomy. In our study, retained CBD stones appeared as late complication, as "thunder on a clear sky":, these patients remained symptom free at least 3 years after cholecystectomy. Three of them had also lithiasis cystic stump, after incomplete cholecystectomy, but unrecorded as an incomplete procedure. We remarked silent CBD stones behaviour, usually very dramatic. All ten late manifested cases were not, in fact, primary CBD lithiasis? Two patients were identified with cystic dilation of CBD, that mandated open surgery with Roux-en Y hepaticojejunostomy (24).
Our study showed several conclusions. The most frequent clinical features appearing after cholecystectomy were caused by retained CBD stones, followed by late non-lithiasis CBD syndrome. Primary CBD lithiasis occurred after the longest symptoms free period.
Cholecystectomy represents a therapeutical procedure decided only by clinical and ultrasound examination criteria. None of these provides valuable evaluation of intra and extrahepatic billiary tract or choledocal-duodenal junction. Cholecystectomy removes the cause of sufferance, but may ignore pathological features yet unexpressed (25); these features will appear later as primary CBD lithiasis or angiocholitis in absence of lithiasis. On the other side, cholecystectomy by itself may cause many late sufferings: retained CBD stones, gallbladder stump lithiasis. It is surprising the high incidence of para-Vater duodenal diverticulum (23.9%) and congenital dilatation of billiary tract (13%) in our study, obviously ignored at the moment of cholecystectomy.
We conclude that the late choledochal pathology may be divided in 2 categories: by omission and iatrogenic.
In first category we include oddian stenosis, first degree congenital dilatation of billiary tract type I and duodenal para-Vater diverticulum. All of these existed by the moment of cholecystectomy, but were not diagnosed, being ignored. These lesions are responsible for late non-lithiasis pathology and primary CBD lithiasis.
In the second category - the iatrogenic pathology - we found complications after surgical procedure: gallbladder (cystic) stump lithiasis or CBD retained stones.
In conclusion, in order to avoid and considerably decrease late postcholecystectomy complications, it appears necessary to perform routine intraoperative cholangiography and duodenal endoscopy for the diagnosis of congenital dilatation of billiary tract, duodenal para-Vater diverticulum and silent CBD lithiasis. Probably we must include these procedures in the standard diagnostic management of gallbladder lithiasis. Even so, 50% of the late complications can not be prevent, as our study shows. We have to emphasize that unexplained primary lithiasis may occur after cholecystectomy without organic lesions able to justify the lithogenesis. The duodenal para-Vater diverticulum seems to have a more important role in billiary disturbances, before and after cholecystectomy.
References
1. Braikov, N. - The so-called postcholecystectomy syndrome in light of the results of endoscopic retrograde cholangiopancreatography. Vutr. Boles., 1991, 30:91.
2. Cooperman, M., Ferrara, J.J., Carey, L.C., Thomas, F.B., Martin, E.W., Fromkes, J. - Endoscopic retrograde cholangiopancreatography. Its use in the evaluation of nonjaundiced patients with the postcholecystectomy syndrome. Arch. Surg., 1981, 116:606.
3. Duca, S. - Postcholecystectomy syndrome. Prophylaxis, Diagnosis, Treatment. Ed. Genesis (Cluj), 1992.
4. Gregg, J.A., Clark, G., Barr, C., McCartney, A., Milano, A., Volcjak, C. - Postcholecystectomy syndrome and its association with ampullary stenosis. Am. J. Surg., 1980, 139:374.
5. Juvara, I., Radulescu, D., Priscu, A. - Postoperative hepato-billiary disease. Ed. Medicalã (Bucuresti), 1972.
6. Konsten, J., Gouma, D.J., von Meyenfeldt, M.F., Menheere, P. - Long-term follow-up after open cholecystectomy, Br. J. Surg., 1993, 80:100.
7. Marotta, F., Hada, R., Morello, P., Vitale, G., Sasaki, M., Ragno, F., Ono, K. - ERCP in the assessment of patients with post-cholecystectomy syndrome: benefits and limitations. Neth. J. Med., 1989, 35:232.
8. Peterli, R., Merki, L., Schuppisser, J.P., Ackermann, C., Herzog, U., Tondelli, P. - Post-cholecystectomy complaints one year after laparoscopic cholecystectomy. Results of a prospective study of 253 patients. Chirurg., 1998, 69:55.
9. Schoenemann, J., Zeidler, J. - Sequelae of cholecystectomy. Z. Gastroenterol., 1997, 35:139.
10. Tocchi, A., Lepre, L., Costa, G., Liotta, G., Mazzoni, G. - The so-called postcholecystectomy syndrome after laparoscopic intervention. G. Chir., 1999, 20:341.
11. Goenka, M.K., Kochhar, R., Nagi, B., Bhasin, D.K., Chowdhury, A., Singh, K. - Endoscopic retrograde cholangiopancreatography in postcholecystectomy syndrome. J. Assoc. Physicians India, 1996, 44:119.
12. Ahrendt, S.A., Pitt, H.A. - Billiary tract. În “Sabiston Textbook of Surgery. The biological basis of modern surgical practice“ sub redactia lui Courtney M. Townsend, Kenneth L Mattox, R. Daniel Beauchamp, Mark Eyers, Daniel R. Beauchamp, 16th Edition. WB Saunders Company (Philadelphia), 2001, pag. 1076-1111.
13. Shaw, C., O'Hanlon, D.M., Fenlon, H.M., McEntee, G.P. - Cystic duct remnant and the "post-cholecystectomy syndrome". Hepatogastroenterology, 2004, 51:36.
14. Dragomirescu, C., Ghida, D., Petrescu, R., Copaescu, C., Litescu, M., Androne, M. - Congenital dilatations of billiary tract late manifested. Chirurgia (Bucur.), 1999, 94:91.
15. Rolny, P., Geenen, J.E., Hogan, W.J. - Post-cholecystectomy patients with "objective signs" of partial bile outflow obstruction: clinical characteristics, sphincter of Oddi mano-metry findings, and results of therapy. Gastrointest. Endosc., 1993, 39:778.
16. Jensen, S.W., Hines, O.J., Talavera, F., Friedman, A.L., Zevitz, M.E., Geibel, J. - Postcholecystectomy syndrome, Last Updated: January 24, 2005. eMedicine.com, Inc.
17. Zhou, P.H., Liu, F.L., Yao, L.Q., Qin, X.Y. - Endoscopic diagnosis and treatment of post-cholecystectomy syndrome. Hepatobiliary Pancreat. Dis. Int., 2003, 2:117.
18. Craig, A.G., Peter, D., Saccone, G.T., Ziesing, P., Wycherley, A., Toouli, J. - Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction. Gut, 2003, 52:352.
19. Cicala, M., Habib, F.I., Vavassori, P., PALLOTTA, N., SCHILLACI, O., COSTAMANGA, G. - Outcome of endoscopic sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction as predicted by manometry and quantitative choledochoscintigraphy. Gut, 2002, 50:665.
20. Singh, V., Kumar, P., Rai, H.S., Singh, K. - Postcholecystectomy problems and the role of endoscopic retrograde cholangiopancreatography, Br. J. Clin. Pract., 1996, 50:183.
21. Tulassay, Z., Papp, J., Kollin, E., Koller, O. - Postcholecystectomy syndrome: endoscopic and radiological aspects, Wien Klin Wochenschr., 1981, 93:55.
22. Starkov, I.u.G., Strekalovskii, V.P., Vishnevskii, V.A., Grigorian, R.S. - Diverticuli of duodenal papillar region and their role in development of choledocholithiasis and strictures of bile and pancreatic ducts, Khirurgiia (Mosk). 2000, 3:10.
23. Kim, D.I., Kim, M.H., Lee, S.K., SEO, D.W., CHOI, W.B., LEE, S.S., PARK, H.J., JOO, Y.H., YOO, K.S., KIM, H.J., MIN, Y.I. - Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy, Gastrointest. Endosc., 2001, 54:42.
24. Popovici, A., Mitulescu, G., Hortopan, M., Stanciu, C. - Congenital dilatations of common bile duct. Chirurgia (Bucur.), 2000, 95:139.
25. Russello, D., Di Stefano, A., Scala, R., Favetta, A., Emmi, S., Guastella, T., Latteri, F. - Does cholecystectomy always resolve biliary disease? Minerva Chir., 1997, 52:1435.
Regarding long-term follow-up after gallbladder removal, our interest was focused on postcholecystectomy syndrome, widely described s1-9t, both after open and laparoscopic surgery s10t. Two types of pathology have been described: organic (26-30%) and functional (70%). This kind of pathology appears in most of the cases in the first 12 postoperative months s3, 8t, specially first 30 days s11t, but can recur even years after cholecystectomy s12-14t. After "simple" cholecystectomy for lithiasis, billiary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. Meantime, a whole range of congenital abnormalities initially ignored can become manifest: billiary tract congenital dilatations, duodenal para-Vater diverticulum, Oddian stenosis. Konsten et al s6t studied 325 patients with cholecystectomy, evaluating ten years postoperative pathology. They found that 18.5% of patients had complaints after cholecystectomy. Marotta et al s7t, followed-up 41 patients with postcholecystectomy syndrome, and found only 36.8% of them asymptomatic, while 34% of them had choledocholithiasis, 9.8% benign choledochal stenosis, 4.9% chronic pancreatitis and rest of them other pathology. Rolny et al s15t identified 17 patients with sphincter of Oddi dysfunctions after mean interval of 18 years postcholecystectomy and showed that endoscopic retrograde cholangiopancreatography (ERCP) is a better diagnosis procedure compared with endoscopic billiary manometry. Finally, Jensen et al s16t and Zhou at al s17t, studying thoroughly the same syndrome, recommended (ERCP) as the best diagnosis procedure, followed by therapeutic measure according to the clinical practice. In the absence of ERCP suggestive findings for organic lesions, endoscopic billiary manometry is needed, also quantitative choledochoscintigraphy, spiral CT or RMN cholangiopancreatography s18, 19t.
The aim of our study was to establish the pathological circumstances that determine late choledochal syndrome, including an analysis concerning the therapeutical approach in these cases.
Patients and methods
Our retrospective study analyzes a group of patients treated in the Surgical Department of University Caritas Hospital "Acad. N. Cajal" Bucharest between 1997 and 2005. Patients previously underwent simple cholecystectomy for lithiasis (open surgery or laparoscopy) in our department or in other surgical departments, and complained of late billiary disorders after 3 years of postoperative asymptomatic period.
In this period, 2487 cholecistectomies, 262 in open surgery and 2225 in laparoscopy (89%) were performed in our department. Meanwhile, 450 endoscopic billiary procedures: 129 diagnostic endoscopic retrograde cholangiopancreatography (ERCP) and 277 ERCP combined with endoscopic sphyncterotomy (ES) were performed. 44 ERCP failures were registered. Intraoperative cholangiography was not performed routinely, but only in selective cases, when indication was established on clinical, laboratory, ultrasonography (US) examination and intraoperative criteria.
The asymptomatic period of at least three years after cholecystectomy years was arbitrarily chosen. This period is usually used in estimation of long-term follow-up results after therapeutically procedures, justifying our option for this period, also after cholecystectomy.
Exclusion criteria of the study were: early difficult post-operative course, with early complications such as retained common bile duct (CBD) stones, angiocholitis, billiary fistulas, etc; incomplete surgical procedure, recognized or accordingly specified: retained CBD stones, incomplete cholecystectomy; intraoperative incidents or accidents noted in operation charts: billiary tract injuries, vascular injuries, etc.
Therapeutical approach was endoscopical (ERCP, diagnostic or combined with ES), surgical or conservative.
Results
Forty-six patients entered the study group, from which 38 previously underwent open cholecystectomy. Seven patients had undergone cholecistectomy in our surgical department, while others referred to our centre after initial operation in other centres. Late choledochal pathology became manifest after an average period of 10 years, ranging from 3 to even 30 years postcholecystectomy. Summing the asymptomatic postoperative periods for all 46 patients included in our trial resulted an amount of 320 years.
Patients were divided in 3 groups: group A - retained choledochal stones (10 patients), group B - primary choledocholitiasis (16 patients) and group C - non-lithiasis choledochal syndrome (20 patients). Etiopathological causes of late choledochal pathology found are reported in table 1.
56.5% of the patients were found with CBD lithiasis, especially primary type (61.5%). Most frequent cause of admission for billiary desobstruction was choledocolithiasis. 41.3% of our patients presented combined causes of late choledochal syndrome.
Therapeutical approach was endoscopic in 38 cases, from which 8 cases failed; 5 patients benefited of conservative treatment after diagnostic ERCP. ERCP combined with ES was successfully applied in 65.2% of our patients. Open surgery was used in 10 cases (21.7%), 2 cases as first choice and 8 after failed endoscopic procedures. 1 patient refused any procedure.
The morbidity and mortality rates of our group were similarly with acceptable rates reported in the literature; however, we did not proposed to analyze these rates in this study.
Group A - Retained choledochal stones: 10 patients
An average asymptomatic period of 4.5 years after cholecystectomy is reported for this group. All patients presented obstructive jaundice. Three patients presented also lithiasic cystic stump, after incomplete cholecystectomy, but unrecorded as an incomplete procedure. The extracted stones were solid, with faceted aspect, suggesting migration, as in the next case:
Case 1: 48 years-old female, presented in 2005 (12 years postcholecystectomy) with right hypocondrial pain, jaundice syndrome, hyperbilirubinemy and inflammatory syndrome. ERCP showed CBD dilatation (30 mm) with papillary stone and segmentary CBD dilatation. ES was performed with stone extraction (fig.1, fig. 2).
We performed 3 open desobstructions, where endoscopic procedure failed. The other 7 patients benefited all of endoscopic treatment. Twelve ES for desobstruction were necessary, sometimes being obliged to enlarge the sphycterotomy in successive step procedures. The endoscopic approach was not complicated, with no need of open surgery.
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Obstructive jaundice was registered in all patients. The interval between cholecystectomy and diagnosis of late choledochal complication averages 14 years with a maximum range 30 years. In only 9 cases (56.2%) we were able to identify a billiary flow obstruction, in order to explain stone formation: 3 inflammatory stenosis of Oddi sphincter, 3 CBD congenital dilatations and 3 duodenal para-Vater diverticulum. The analysis showed that just 9 cases of all 16 presented anatomical and functionally circumstances capable of altering billiary hydrodynamics. No evident pathological changes capable to explain the appearance of late CBD stones after cholecystectomy were identified in the other 7 patients. We present one of these cases, illustrated in fig. 3.
Case 2: 48 years-old female, 5 years postcholecystectomy, presented in our clinic with right hypocondrial pain, jaundice syndrome, hyperbilirubinemy, leucocytosis and transitory hepatic cytolysis. Preoperative US examination showed CBD dilatation (15-17mm) with distal choledochal stone. ERCP confirmed CBD lithiasis and ES was performed with stone extraction; good immediate postoperative evolution was registered, with total remission of complains.
The CBD stones identified in patients from group B had primary stones features: soft, browny, earthy in consistency, crumbly. Therapeutical approach was endoscopical in 10 cases and open surgery in other 6 cases. Overall we performed 20 ES, of which 10 were iterative sphyncterotomies, some of patients requiring 2 or 3 step by step procedures. Endoscopical failures were caused by CBD panlithiasis (2 patients) or the large size of stones (2 patients). Cystic dilation of CBD (2 cases) mandated open surgery with Roux-en Y hepaticojejunostomy.
In summary, in 26 cases from groups A and B (CBD stones, primary and residual), 32 ES were performed, 15 of them being iterative. Seven endoscopic desobstruction failures were registered, 3 retained and 4 primary CBD stones, in which open-surgery was required. In 2 cases the open surgery was the first choice, excluding the endoscopic approach.
Group C - non lithiasis CBD syndrome 20 patients
Clinical findings were upper abdominal pain, angiocholitis and jaundice syndrome caused by: a) Oddian stenosis in 9 cases, 3 of them occurred as recurrences after ES performed for postcholecystectomy syndrome manifested over 3 years postoperative; b) duodenal para-Vater diverticulum 8 cases; c) cholestatic hepatitis with sclerosing cholangitis 2 cases; d) congenital dilatation of billiary tract type I in 3 cases; e) gallbladder (cystic) stump lithiasis, without CBD lithiasis in 2 cases.
Plurifactorial etiology was observed in this group had; therefore each patient had many pathological circumstances. Clinical features were scarce, unlike in lithiasis CBD syndrome: clinical jaundice was found in just 7 cases. The main symptoms were upper abdominal pain, angiocholitis and jaundice being of low intensity and of short duration.
The mean period between cholecystectomy and late choledochal syndrome occurrence was 9 years. Treatment consisted in 14 ES, some of them being iterative: 9 required for oddian stenosis; 4 for a "tactical" or "safety" indication: in 2 cases cholestatic hepatitis and in 2 cases with gallbladder (cystic) stump lithiasis. One endoscopic desobstruction failure was registered caused by cystic stump lithiasis and open-surgery was required.
Case 3: 66 years-old female, presented in 2003 (3 years after cholecystectomy) with epigastric pain, angiocholitis, jaundice syndrome, hyperbilirubinemy, leucocytosis and hepatic cytolysis. Preoperative US showed large dilatation of CBD (22 mm) and intrahepatic billiary tree and also distal CBD stones. Endoscopic approach showed periampullary diverticulum, dilatation of cystic stump with an 18 mm stone, and moderate dilatation of CBD. ES was performed. Open surgery removed the stone from the cystic stump; explorative choledocotomy with cholangiography ended with Kehr drainage. Positive immediate postoperative evolution was registered (fig. 4, fig. 5).
One patient refused ES; therefore we abstained from any procedure. ES was first choice even in cases with congenital dilatation of billiary tract, without lithiasis, as it shows case further presented:
Case 4: 67 years-old female, presented in 2002 (29 years after cholecystectomy) with epigastric pain, jaundice syndrome, hyperbilirubinemy, leucocytosis and hepatic cytolysis. Preoperative US showed dilatation of CBD (14mm) with moderate dilatation of intrahepatic billiary tree. ERCP showed CBD dilatation (18 mm) with CBD diverticulum and long cystic stump retroduodenally inserted. ES was performed with good immediate postoperative evolution (fig. 6).
The other 5 patients from group C did not require endoscopical desobstruction or open surgery, conservative treatment being effective.
In summary, regarding the therapeutical management of entire study group, endoscopic treatment was possible in 30 patients (table 2). Thirty-six ES were performed, some of them iterative, choosing gradual sphyncterotomy for decreasing the rate of bleeding or obtaining a total desobstruction when first step was incomplete. In 8 cases, the endoscopic procedure failed: 3 cases with retained CBD stones, 4 cases with primary CBD lithiasis and 1 case with cystic stump lithiasis; one patient was uncompliant.
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We chose to analyse the late choledochal pathology because, unfortunately, it is found in all hepato-billiary surgical departments. Singh et al (19), published a study consist of patients with complains 7 years postcholecystectomy. Billiary pathology was found in 70% of cases. In other studies, Tulassay et al (21) and Coopermann et al s2t, found at the ERCP examination 56% and 52%, respective, late postoperative lesions. Starkov et al (22) revealed the presence of duodenal para-Vater diverticulum in 30% of the patients with postcholecystectomy syndrome. From 87 patients identified with para-Vater duodenal diverticulum, 47% had CBD lithiasis, 15% CBD stenosis and 10% Oddian stenosis. Therefore, para-Vater duodenal diverticulum represents one of the bases of billio-pancreatic pathology. Kim et al (23) also underline the high risk of recurrent CBD lithiasis in patients with para-Vater duodenal diverticulum.
The puzzling remark was that a group of patients with "simple" cholecystectomy, considered without doubted initially as therapeutically achievements, developed an unexpected and not negligible pathology, increasing the rate of late complications after billiary surgery, all this after proper surgical indication and technique, without intraoperative incidents or accidents. We found out that, even after a "simple" cholecistecomy, late complications, hard to explain, can occur: angiocholitis, jaundice syndrome, late CBD lithiasis, inflammatory stenosis, undiagnosed congenital dilatations of billiary tract, para-Vater duodenal diverticulum, etc. Some of this pathology, preceded cholecystectomy, but escaped detection. For elucidating this unclear pathology, we excluded patients with early difficult postoperative evolution.
We were trying to focus on silent complications started after three years postcholecystectomy. It is surprising to find out the long period of arising of primary CBD stones. It is possible that"late" term, from the title, could cause some misunderstanding. This interval was arbitrary chosen, but based on the evidence of possible late onset (12-14). We are dealing with a latent pathology, late manifested. Because we encountered such cases, even after so called "ordinary" billiary surgery, we approached this group of patients, in order to find the real reasons of this type of pathology.
Most of the cholecystectomies were done in open surgery (82.6%), due to general diffusion of the approach at the era. The "oldest" cholecystectomy from our group was done in 1965. We believe that in the future this rate will be inverted, meaning that type of pathology will be prevalent after laparoscopic approach. Billiary symptomatology after laparoscopic procedure is generally attributed to the longer cystic duct remnant, defined as a residual duct greater than 1 cm in length (12, 13).
From entire list of late choledochal pathology, only retained CBD stones suggests an incomplete surgical act, as might be appreciated as "faulty repair". It is not something unusual, because CBD retained stones are reported in the most significant statistics, even those where perioperative cholangiography is performed routinely. This early complication, extremely unpleasant for the surgeon, usually becomes manifested in the first 30-45 days after cholecystectomy. In our study, retained CBD stones appeared as late complication, as "thunder on a clear sky":, these patients remained symptom free at least 3 years after cholecystectomy. Three of them had also lithiasis cystic stump, after incomplete cholecystectomy, but unrecorded as an incomplete procedure. We remarked silent CBD stones behaviour, usually very dramatic. All ten late manifested cases were not, in fact, primary CBD lithiasis? Two patients were identified with cystic dilation of CBD, that mandated open surgery with Roux-en Y hepaticojejunostomy (24).
Our study showed several conclusions. The most frequent clinical features appearing after cholecystectomy were caused by retained CBD stones, followed by late non-lithiasis CBD syndrome. Primary CBD lithiasis occurred after the longest symptoms free period.
Cholecystectomy represents a therapeutical procedure decided only by clinical and ultrasound examination criteria. None of these provides valuable evaluation of intra and extrahepatic billiary tract or choledocal-duodenal junction. Cholecystectomy removes the cause of sufferance, but may ignore pathological features yet unexpressed (25); these features will appear later as primary CBD lithiasis or angiocholitis in absence of lithiasis. On the other side, cholecystectomy by itself may cause many late sufferings: retained CBD stones, gallbladder stump lithiasis. It is surprising the high incidence of para-Vater duodenal diverticulum (23.9%) and congenital dilatation of billiary tract (13%) in our study, obviously ignored at the moment of cholecystectomy.
We conclude that the late choledochal pathology may be divided in 2 categories: by omission and iatrogenic.
In first category we include oddian stenosis, first degree congenital dilatation of billiary tract type I and duodenal para-Vater diverticulum. All of these existed by the moment of cholecystectomy, but were not diagnosed, being ignored. These lesions are responsible for late non-lithiasis pathology and primary CBD lithiasis.
In the second category - the iatrogenic pathology - we found complications after surgical procedure: gallbladder (cystic) stump lithiasis or CBD retained stones.
In conclusion, in order to avoid and considerably decrease late postcholecystectomy complications, it appears necessary to perform routine intraoperative cholangiography and duodenal endoscopy for the diagnosis of congenital dilatation of billiary tract, duodenal para-Vater diverticulum and silent CBD lithiasis. Probably we must include these procedures in the standard diagnostic management of gallbladder lithiasis. Even so, 50% of the late complications can not be prevent, as our study shows. We have to emphasize that unexplained primary lithiasis may occur after cholecystectomy without organic lesions able to justify the lithogenesis. The duodenal para-Vater diverticulum seems to have a more important role in billiary disturbances, before and after cholecystectomy.
References
1. Braikov, N. - The so-called postcholecystectomy syndrome in light of the results of endoscopic retrograde cholangiopancreatography. Vutr. Boles., 1991, 30:91.
2. Cooperman, M., Ferrara, J.J., Carey, L.C., Thomas, F.B., Martin, E.W., Fromkes, J. - Endoscopic retrograde cholangiopancreatography. Its use in the evaluation of nonjaundiced patients with the postcholecystectomy syndrome. Arch. Surg., 1981, 116:606.
3. Duca, S. - Postcholecystectomy syndrome. Prophylaxis, Diagnosis, Treatment. Ed. Genesis (Cluj), 1992.
4. Gregg, J.A., Clark, G., Barr, C., McCartney, A., Milano, A., Volcjak, C. - Postcholecystectomy syndrome and its association with ampullary stenosis. Am. J. Surg., 1980, 139:374.
5. Juvara, I., Radulescu, D., Priscu, A. - Postoperative hepato-billiary disease. Ed. Medicalã (Bucuresti), 1972.
6. Konsten, J., Gouma, D.J., von Meyenfeldt, M.F., Menheere, P. - Long-term follow-up after open cholecystectomy, Br. J. Surg., 1993, 80:100.
7. Marotta, F., Hada, R., Morello, P., Vitale, G., Sasaki, M., Ragno, F., Ono, K. - ERCP in the assessment of patients with post-cholecystectomy syndrome: benefits and limitations. Neth. J. Med., 1989, 35:232.
8. Peterli, R., Merki, L., Schuppisser, J.P., Ackermann, C., Herzog, U., Tondelli, P. - Post-cholecystectomy complaints one year after laparoscopic cholecystectomy. Results of a prospective study of 253 patients. Chirurg., 1998, 69:55.
9. Schoenemann, J., Zeidler, J. - Sequelae of cholecystectomy. Z. Gastroenterol., 1997, 35:139.
10. Tocchi, A., Lepre, L., Costa, G., Liotta, G., Mazzoni, G. - The so-called postcholecystectomy syndrome after laparoscopic intervention. G. Chir., 1999, 20:341.
11. Goenka, M.K., Kochhar, R., Nagi, B., Bhasin, D.K., Chowdhury, A., Singh, K. - Endoscopic retrograde cholangiopancreatography in postcholecystectomy syndrome. J. Assoc. Physicians India, 1996, 44:119.
12. Ahrendt, S.A., Pitt, H.A. - Billiary tract. În “Sabiston Textbook of Surgery. The biological basis of modern surgical practice“ sub redactia lui Courtney M. Townsend, Kenneth L Mattox, R. Daniel Beauchamp, Mark Eyers, Daniel R. Beauchamp, 16th Edition. WB Saunders Company (Philadelphia), 2001, pag. 1076-1111.
13. Shaw, C., O'Hanlon, D.M., Fenlon, H.M., McEntee, G.P. - Cystic duct remnant and the "post-cholecystectomy syndrome". Hepatogastroenterology, 2004, 51:36.
14. Dragomirescu, C., Ghida, D., Petrescu, R., Copaescu, C., Litescu, M., Androne, M. - Congenital dilatations of billiary tract late manifested. Chirurgia (Bucur.), 1999, 94:91.
15. Rolny, P., Geenen, J.E., Hogan, W.J. - Post-cholecystectomy patients with "objective signs" of partial bile outflow obstruction: clinical characteristics, sphincter of Oddi mano-metry findings, and results of therapy. Gastrointest. Endosc., 1993, 39:778.
16. Jensen, S.W., Hines, O.J., Talavera, F., Friedman, A.L., Zevitz, M.E., Geibel, J. - Postcholecystectomy syndrome, Last Updated: January 24, 2005. eMedicine.com, Inc.
17. Zhou, P.H., Liu, F.L., Yao, L.Q., Qin, X.Y. - Endoscopic diagnosis and treatment of post-cholecystectomy syndrome. Hepatobiliary Pancreat. Dis. Int., 2003, 2:117.
18. Craig, A.G., Peter, D., Saccone, G.T., Ziesing, P., Wycherley, A., Toouli, J. - Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction. Gut, 2003, 52:352.
19. Cicala, M., Habib, F.I., Vavassori, P., PALLOTTA, N., SCHILLACI, O., COSTAMANGA, G. - Outcome of endoscopic sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction as predicted by manometry and quantitative choledochoscintigraphy. Gut, 2002, 50:665.
20. Singh, V., Kumar, P., Rai, H.S., Singh, K. - Postcholecystectomy problems and the role of endoscopic retrograde cholangiopancreatography, Br. J. Clin. Pract., 1996, 50:183.
21. Tulassay, Z., Papp, J., Kollin, E., Koller, O. - Postcholecystectomy syndrome: endoscopic and radiological aspects, Wien Klin Wochenschr., 1981, 93:55.
22. Starkov, I.u.G., Strekalovskii, V.P., Vishnevskii, V.A., Grigorian, R.S. - Diverticuli of duodenal papillar region and their role in development of choledocholithiasis and strictures of bile and pancreatic ducts, Khirurgiia (Mosk). 2000, 3:10.
23. Kim, D.I., Kim, M.H., Lee, S.K., SEO, D.W., CHOI, W.B., LEE, S.S., PARK, H.J., JOO, Y.H., YOO, K.S., KIM, H.J., MIN, Y.I. - Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy, Gastrointest. Endosc., 2001, 54:42.
24. Popovici, A., Mitulescu, G., Hortopan, M., Stanciu, C. - Congenital dilatations of common bile duct. Chirurgia (Bucur.), 2000, 95:139.
25. Russello, D., Di Stefano, A., Scala, R., Favetta, A., Emmi, S., Guastella, T., Latteri, F. - Does cholecystectomy always resolve biliary disease? Minerva Chir., 1997, 52:1435.