Postcholecystectomy Syndrome Kathy Lee June 23, 2006
Transcript of Postcholecystectomy Syndrome Kathy Lee June 23, 2006
Postcholecystectomy Syndrome
Kathy LeeJune 23 2006
Introduction
bull First described in 1947bull Presence of symptoms after
cholecystectomybull May be either
ndash Development of new Sx ORndash Continuation of Sx
bull 10-15 of patients
bull Pain may persist recur mos or yrsbull Preliminary Dx should be renamed
relevant to the disease identified by an adequate workupndash Cause for PCS identified in 95 of patients
Preop Risk stratification
bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed
bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill
Symptoms
bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24
Etiology
SO dyskinesia spasm or hypertrophy
SO stricturePapilloma Cancer
PeriampullaryResidual GBStump cholelithiasisNeuroma
GB remnant and cystic duct
Liver
Anatomy
Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst
Etiology
CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or
nonspecific dilationDyskinesiaFistula
Biliary tract
EtiologyAnatomy
Intestinal anginaCoronary angina
VascularArthritisBone
AdhesionsIncisional herniaIrritable bowel disease
Small bowel
AdhesionsDiverticulaIrritable bowel disease
Duodenum
EtiologyAnatomyEtiologyAnatomy
ConstipationDiarrheaIncisional herniaIBS
ColonPancreatitisStoneCancer
Pancreas
Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx
Other
NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety
Nerve
Bile gastritisPUDGastric cancer
StomachDiaphragmatic herniaHiatal herniaAchalasia
Esophagus
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Introduction
bull First described in 1947bull Presence of symptoms after
cholecystectomybull May be either
ndash Development of new Sx ORndash Continuation of Sx
bull 10-15 of patients
bull Pain may persist recur mos or yrsbull Preliminary Dx should be renamed
relevant to the disease identified by an adequate workupndash Cause for PCS identified in 95 of patients
Preop Risk stratification
bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed
bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill
Symptoms
bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24
Etiology
SO dyskinesia spasm or hypertrophy
SO stricturePapilloma Cancer
PeriampullaryResidual GBStump cholelithiasisNeuroma
GB remnant and cystic duct
Liver
Anatomy
Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst
Etiology
CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or
nonspecific dilationDyskinesiaFistula
Biliary tract
EtiologyAnatomy
Intestinal anginaCoronary angina
VascularArthritisBone
AdhesionsIncisional herniaIrritable bowel disease
Small bowel
AdhesionsDiverticulaIrritable bowel disease
Duodenum
EtiologyAnatomyEtiologyAnatomy
ConstipationDiarrheaIncisional herniaIBS
ColonPancreatitisStoneCancer
Pancreas
Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx
Other
NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety
Nerve
Bile gastritisPUDGastric cancer
StomachDiaphragmatic herniaHiatal herniaAchalasia
Esophagus
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
bull Pain may persist recur mos or yrsbull Preliminary Dx should be renamed
relevant to the disease identified by an adequate workupndash Cause for PCS identified in 95 of patients
Preop Risk stratification
bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed
bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill
Symptoms
bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24
Etiology
SO dyskinesia spasm or hypertrophy
SO stricturePapilloma Cancer
PeriampullaryResidual GBStump cholelithiasisNeuroma
GB remnant and cystic duct
Liver
Anatomy
Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst
Etiology
CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or
nonspecific dilationDyskinesiaFistula
Biliary tract
EtiologyAnatomy
Intestinal anginaCoronary angina
VascularArthritisBone
AdhesionsIncisional herniaIrritable bowel disease
Small bowel
AdhesionsDiverticulaIrritable bowel disease
Duodenum
EtiologyAnatomyEtiologyAnatomy
ConstipationDiarrheaIncisional herniaIBS
ColonPancreatitisStoneCancer
Pancreas
Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx
Other
NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety
Nerve
Bile gastritisPUDGastric cancer
StomachDiaphragmatic herniaHiatal herniaAchalasia
Esophagus
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Preop Risk stratification
bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed
bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill
Symptoms
bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24
Etiology
SO dyskinesia spasm or hypertrophy
SO stricturePapilloma Cancer
PeriampullaryResidual GBStump cholelithiasisNeuroma
GB remnant and cystic duct
Liver
Anatomy
Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst
Etiology
CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or
nonspecific dilationDyskinesiaFistula
Biliary tract
EtiologyAnatomy
Intestinal anginaCoronary angina
VascularArthritisBone
AdhesionsIncisional herniaIrritable bowel disease
Small bowel
AdhesionsDiverticulaIrritable bowel disease
Duodenum
EtiologyAnatomyEtiologyAnatomy
ConstipationDiarrheaIncisional herniaIBS
ColonPancreatitisStoneCancer
Pancreas
Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx
Other
NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety
Nerve
Bile gastritisPUDGastric cancer
StomachDiaphragmatic herniaHiatal herniaAchalasia
Esophagus
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Symptoms
bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24
Etiology
SO dyskinesia spasm or hypertrophy
SO stricturePapilloma Cancer
PeriampullaryResidual GBStump cholelithiasisNeuroma
GB remnant and cystic duct
Liver
Anatomy
Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst
Etiology
CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or
nonspecific dilationDyskinesiaFistula
Biliary tract
EtiologyAnatomy
Intestinal anginaCoronary angina
VascularArthritisBone
AdhesionsIncisional herniaIrritable bowel disease
Small bowel
AdhesionsDiverticulaIrritable bowel disease
Duodenum
EtiologyAnatomyEtiologyAnatomy
ConstipationDiarrheaIncisional herniaIBS
ColonPancreatitisStoneCancer
Pancreas
Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx
Other
NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety
Nerve
Bile gastritisPUDGastric cancer
StomachDiaphragmatic herniaHiatal herniaAchalasia
Esophagus
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Etiology
SO dyskinesia spasm or hypertrophy
SO stricturePapilloma Cancer
PeriampullaryResidual GBStump cholelithiasisNeuroma
GB remnant and cystic duct
Liver
Anatomy
Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst
Etiology
CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or
nonspecific dilationDyskinesiaFistula
Biliary tract
EtiologyAnatomy
Intestinal anginaCoronary angina
VascularArthritisBone
AdhesionsIncisional herniaIrritable bowel disease
Small bowel
AdhesionsDiverticulaIrritable bowel disease
Duodenum
EtiologyAnatomyEtiologyAnatomy
ConstipationDiarrheaIncisional herniaIBS
ColonPancreatitisStoneCancer
Pancreas
Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx
Other
NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety
Nerve
Bile gastritisPUDGastric cancer
StomachDiaphragmatic herniaHiatal herniaAchalasia
Esophagus
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Intestinal anginaCoronary angina
VascularArthritisBone
AdhesionsIncisional herniaIrritable bowel disease
Small bowel
AdhesionsDiverticulaIrritable bowel disease
Duodenum
EtiologyAnatomyEtiologyAnatomy
ConstipationDiarrheaIncisional herniaIBS
ColonPancreatitisStoneCancer
Pancreas
Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx
Other
NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety
Nerve
Bile gastritisPUDGastric cancer
StomachDiaphragmatic herniaHiatal herniaAchalasia
Esophagus
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Workup
bull Hx Pxbull Labs
ndash Incl LFT INRPTT amylase bili
bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction
bull Therapeutic as well stone extraction stricture dilation sphincterotomy
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
More common causes
bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak
bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis
bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize
BD injuries no increased biliary symptom
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Outline
Sphincter of Oddi dysfunction
Retained Stone
Bile Duct Injury
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Sphincter of Oddi Dysfunction
bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla
of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration
operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes
bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium
from CBDndash uarr basal sphincter pressure gt40mmHg
bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates
but evidence not convincingbull Tx sphincterotomy (endoscopic or
transduodenal)ndash Mucosa-mucosa apposition in surgical approach can
minimize scarring and restenosisndash Results of both treatment similar more dependent on
presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective
evidence
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Retained stones
bull More likely to occur with lap chole esp if no IOC done
bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v
pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole
(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Bile duct injury
bull Most feared complication bull Most recognized intraoperatively or during early
postop periodbull Long-term results acceptable with appropriate
managementndash Otherwise recurrent cholangitis secondary biliary
cirrhosis portal hypertension
bull Lap chole greater risk than open chole for bile duct injury
bull 1 in 120 lap chole major BDI 055 minor 03
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Proportion of BDI by IOC type of surgery and case complexity
1310583317862Not complex
22446169295Complex
107632274017Open
213397434140Laparoscopic
Injuries per 1000
Total cases
Injuries per 1000
Total cases
IOC YesIOC No
Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Risk Factors
bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD
bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks
bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure
bleeding obscuring operative fieldndash Aberrant biliary anatomy
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Strasbergrsquos view of safety
Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Classic lap chole BDI
GB and CBD aligned by traction of GB
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Prevention
bull Routine operative cholangiography reduce 50 of BDI or bile leak
bull Define anatomy and limit the extent of biliary injury
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Presentation
bull 25 of ductal injuries recognized intraopbull Presentation within 1wk
ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct
ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia
bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Diagnosis
bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to
delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy
bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire
liver
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Management
bull Appropriate management depends on time of Dx type extent and level of injury
bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube
ndash At site of injuryndash If more extensive injury repaired primarily and stented
bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct
enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or
hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts
ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Results
bull Operative mort lt1bull Complication incl cholangitis subhepatic or
subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis
ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)
ndash Perc balloon dilation with stenting lower success rate (64)
bull Lower quality of life surveys esp in psychological domain even years after successful repair
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
References
bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006
bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug
bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun
bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May
bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr
bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul
bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Disc
Kayvan
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-
Samaad clapping
Ray praying
Kayvan checking out ldquothe viewrdquo
- Postcholecystectomy Syndrome
- Introduction
- Slide 3
- Preop Risk stratification
- Symptoms
- Etiology
- Slide 7
- Workup
- More common causes
- Outline
- Sphincter of Oddi Dysfunction
- Slide 12
- Retained stones
- Bile duct injury
- Proportion of BDI by IOC type of surgery and case complexity
- Risk Factors
- Strasbergrsquos view of safety
- Classic lap chole BDI
- Slide 19
- Prevention
- Presentation
- Diagnosis
- Management
- Results
- References
- Slide 26
- Slide 27
-