Post-cholecystectomy syndrome in pediatric patients: Occurrence and spectrum of symptoms

BACKGROUND

Post-cholecystectomy syndrome (PCS) refers to persistent or new abdominal symptoms after cholecystectomy. As there are very few reports on PCS in pediatric patients, we aimed to examine whether it was a frequent finding and which symptoms the affected children experienced.

METHOD

This is a retrospective cross sectional study of pediatric patients, who underwent cholecystectomy during 2003-2019 at Oslo University Hospital. The PedsQL™ gastrointestinal symptoms scale questionnaire and a self-designed questionnaire exploring satisfaction after surgery and current medical conditions were mailed to all eligible patients. Patient/parental consent and approval from the local data protection officer (19/09054) were obtained.

RESULTS

Questionnaires were sent to 82 patients of whom 44 (54%) answered. There were no significant demographic differences between the responders and the non responders. We identified 16 (36.7%) patients to have PCS. The most common symptoms were diarrhea (25%), bloating (16%), and heartburn/reflux (16%). Overweight was more common in patients with PCS (31%) than in patients without PCS (4%) (p = 0.014). Altogether 34/44 (77.3%) patients were satisfied with the result of the cholecystectomy; 92,6% of patients without PCS and 56.6% of those with PCS (p = 0.012).

CONCLUSION

PCS is not uncommon in pediatric patients, and they report a wide range of gastrointestinal symptoms. We identified overweight as a potential risk factor for developing PCS. Nonetheless, most patients got total relief of abdominal pain and were satisfied with outcome after cholecystectomy.

LEVEL OF EVIDENCE

Level 3.

[Aneurysm of the gastroduodenal artery in a female patient with the postcholecystectomy syndrome (a clinical case report)]

Aneurysms of visceral arteries appear to belong to rare and potentially lethal vascular diseases. The most important role in the aetiology of aneurysms of the gastroduodenal artery is plaid by either acute or chronic pancreatitis. The article deals with a clinical case report concerning a saccular partially thrombosed aneurysm having developed in a 77-year-old woman presenting with the postcholecystectomic syndrome and detected on ultrasonographic examination of the abdominal-cavity vessels. Timely radiodiagnosis (SCT angiography of abdominal cavity vessels), adequate and timely performed endovascular occlusion of the cavity of the aneurysm with metal spirals performed in a timely manner made it possible to attain a favourable outcome. Little is known regarding the understanding of the aetiology and lack of full clarity in therapeutic approaches to aneurysms of visceral arteries predetermine the necessity to continue collecting clinical case reports concerning this rarely encountered vascular pathology in order to generalize and work out an appropriate therapeutic-and-diagnostic algorithm.

[Postcholecystectomy syndrome in children, fact or fiction?]

INTRODUCTION

The postcholecystectomy syndrome (SPC) is broadly defined and published in adults, whereas in the pediatric population are hardly any articles about it. Up to a third of adults have dyspeptic symptoms without organic cause the first year after cholecystectomy. Our goal is to determine the incidence of SPC in our population.

METHODS

An observational study was performed, collecting data from patients who had been done laparoscopic cholecystectomy in our hospital since 2005. Patients diagnosed choledochal cyst and biliary atresia were excluded. The following data were collected: type of dyspeptic symptoms, scheduled office visits and emergency units in the first postoperative year and in the following. Children who did not make any visits, a telephone survey was conducted.

RESULTS

Data from 36 patients, including 3 patients who were excluded for presenting organic cause, were collected. The most frequent diagnosis was idiopathic cholelithiasis (64,7%). Sixteen children (48,5%) had postoperative symptoms in the first year, of which 14 went to scheduled office visit and 6 emergent (2 required hospitalization). The main symptoms were abdominal postoperative pain (100%), nausea (62,5%) and vomiting (50%). After the first year (6 patients were excluded for less follow-up), only 5 patients (18,5%) continued to symptoms (p= 0,015), 2 required visit to programmatically consultation and no one emergent.

CONCLUSION

In our sample, SPC in children exists and improves after the first year. So postoperative follow-up is an important fact, and only further tests must be done if signs of organic cause.

Post-laparoscopic cholecystectomy Mirizzi syndrome induced by polymeric surgical clips: a case report and review of the literature

BACKGROUND

Laparoscopic cholecystectomy is the gold standard treatment of gallbladder disease. Post-cholecystectomy syndrome is a severe postoperative complication which can be caused by multiple mechanisms and can present with multiple disorders. The wide use of laparoscopy induces the need to understand more clearly the presentation and pathophysiology of this syndrome. Post-cholecystectomy Mirizzi syndrome is one form of this syndrome and, according to literature, this is the first report that clearly describes it.

CASE PRESENTATION

We describe the case of a 62-year-old Greek woman who underwent laparoscopic cholecystectomy because of gallstone disease. A few days after surgery, post-cholecystectomy syndrome gradually developed with mild bilirubin increase in association with epigastric pain, nausea, and vomiting. After performing ultrasound, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography, we conducted a second laparoscopic surgery to manage the obstruction, which was converted to open surgery because of the remaining inflammation from the post-endoscopic retrograde cholangiopancreatography acute pancreatitis. Four polymeric laparoscopic clips were removed because they were identified as the cause of her post-cholecystectomy syndrome. She had a quick recovery without further complications.

CONCLUSIONS

Postoperative Mirizzi syndrome induced by the migration of polymer laparoscopic clips is a rare (only one case referring to polymeric clips has been published in the literature) but a well-identified complication of laparoscopic cholecystectomy which can confuse the diagnostic and therapeutic field requiring simultaneous immediate management.

[Cholagenic diarrhea is a type of postcholescystectomy syndrome]

AIM

To study the role of biliary acids (BAs) in the pathogenesis of chronic diarrhea (CD) in patients undergoing cholecystectomy (CE).

SUBJECTS AND METHODS

Twenty-five patients with post-CE diarrhea were examined. A comparison group consisted of 11 patients with diarrhea-predominant irritable bowel syndrome (IBS). The results of an examination of 15 healthy individuals were taken as normal values. Daily fecal BAs were determined by an enzyme spectrophotometric technique.

RESULTS

In the patients after CE, daily fecal BA losses were found to be thrice as large as that in the healthy individuals. In the comparison group of patients with IBS, fecal bile excretion was not greater than the normal values. Stool normalization with a simultaneous decrease in fecal BA losses was seen in 92% of the post-CE patients receiving a course of therapy with adsorbents and astringents.

CONCLUSION

Post-CE CD is a type of postcholescystectomy syndrome.

[Forced resection of the liver right lobe in the patient with cholelithiasis]

There is a case of cholelithic illness complicated by cholangiolithiasis, the treatment of which resulted in resection of the right hepatic lobe.

[The role of bile acids in the pathogenesis of chronic diarrhea]

Chronic diarrhea syndrome results from excess colonic bile acids. Fibroblast growth factor 19 (FGF19), produced in the ileum is response to bile acid absorption, regulates hepatic bile acids synthesis. Bile acid malabsorption can be found in various gastrointestinal conditions: the greatest losses bile acids with excrements were marked at patients with surgical resection of terminal ileum. The maintenance in daily colonic excess bile at patients with postholecystectomy exceed more than in three times the indicators noted at control subjects, but at the patients with irritable bowel sindrom did not exceed the norm. Effective remedies in treatment chologenic diarrhea were bile acid sequestran.

[Clinico-morphological characteristics of major duodenal papilla benign neoformations of patients with postcholecystectomy syndrome]

The article is devoted to a problem of diagnosis and treatment of postcholecystectomy syndrome caused by benign neoformations of the major duodenal papilla. The material of study was formed by 76 patients; among them 53 ones had isolated benign neoformations of the major duodenal papilla. The medical-diagnostic algorithm applied by authors for the examination of patients with postcholecystectomy syndrome is presented. It's been defined, that benign neoformations of the major duodenal papilla take an essential place in the structure of postcholecystectomy syndrome and make 13.5% of the reasons of its occurrence. Thus, the most widespread morphological substratum of these benign neoformations is the hyperplastic polyp.

[Efficacy of rifaximine in small intestinal bacterial overgrowth syndrome in patients after cholecystectomy]

AIM

To define frequency of onset of small intestinal bacterial overgrowth syndrome (SIBOGS) in patients with postcholecystectomy syndrome (PCS); to substantiate necessity of microflora correction and assess efficacy of rifaximine in the doses 800 and 1200 mg/day.

MATERIAL AND METHODS

A breath hydrogen test (BHT) was made in 82 PCS patients. Rifaximine was given to 40 SIBOGS patients: 20 of them received the drug in a dose 800 mg/day and 20--in a dose 1200 mg/day for 7 days. The efficacy was estimated by attenuation of the clinical symptoms and parameters of BHT.

RESULTS

SIBOGS was detected in 73% of PCS patients. This was an indication for antibacterial treatment. Rifaximine in a dose 800 mg/day failed to attenuate pain and to eliminate dyspeptic syndromes in some patients, BHT in them was not normal. Administration of rifaximine in a dose 1200 mg/day normalized BHT in 90% patients and eliminated clinical symptoms in most of the patients.

CONCLUSION

Rifaximine in a dose 1200 mg/day vs 800 mg/day in PCS patients with SIBOGS is more effective as it eliminates clinical symptoms and normalizes BHT.

[Disorders of bone mineral density in patients with cholelithiasis and postcholecystectomic syndrome]

to justify the role of biliary insufficiency (BI) in the development of disorders of bone mineral density (BMD) in patients with cholelithiasis and after cholecystectomy, to introduce with main methods of diagnosis, prevention and treatment of osteoporosis and osteopenia in biliary pathology. Recent literature data showed that development of BI in the CL and PS leads to malabsorption of vitamin D and thereby contribute to the development of osteoporosis and osteopenia. The main method of diagnosis of BMD is twoenergic X-ray densitometry.

Postcholecystectomy syndrome with special regard to children--a review

The incidence of abdominal symptoms after cholecystectomy in adults is high. Up to one third of the patients consult a doctor because of abdominal complaints within 1 year after the operation. In addition, a higher incidence of colon carcinoma after cholecystectomy has been reported in female patients. This article reviews the known facts on the "postcholecystectomy syndrome". However, little is known about postcholecystectomy symptoms in children. Reports on cholecystectomy in children deal rather with feasibility than long-term outcome. Therapeutic concepts for children with symptomatic gallstone disease should consider the differences in the etiology of gallstone formation between children and adults. Therefore, we recommend a specific concept, including laparoscopic cholecystotomy, for children with temporary disorders causing gallstones, and laparoscopic cholecystectomy for all other patients. The impact of these procedures on postcholecystectomy symptoms in children and the impact of cholecystectomy during childhood on the incidence of right-sided colonic carcinoma remains to be determined.

Hepatic abscess as a complication of the sump syndrome

We report a case of hepatic abscess associated with the sump syndrome. The patient was a 66-year-old woman who had undergone cholecystectomy and side-to-side choledochoduodenostomy for a common bile duct (CBD) stone in 1983, and who presented with fever and right lower chest pain. A hepatic abscess was diagnosed; after it was drained, percutaneous transhepatic biliary drainage was performed. Bacteriological studies revealed the presence of Bacteroides fragilis and Streptococcus intermedius in the pus in the hepatic abscess cavity, and Klebsiella pneumoniae and Pseudomonas aeruginosa in the bile. The hepatic abscess and cholangitis rapidly resolved in response to two drainage procedures. At surgery, simple closure of the anastomosis was performed, because free drainage was observed from the distal CBD into the duodenum, despite the existence of a periampullary diverticulum.

[Recurrent and residual choledocholithiasis]

Many years' experience in treatment of 617 patients with choledocholithiasis (ChDL) served the basis for analysis of the causes of residual (72.4%) and recurrent (21.4%) lithiasis of bile ducts in patients with postcholecystectomy syndrome. In 6.2% of cases identification of the type of ChDL was not a success. Recommendations in prophylaxis of recurrent as well as residual lithiasis are given. In 78.5% of patients with residual stones after primary operation choledochotomy with removal of the stones was made with cholecystectomy but as was evidenced later not all the stones were removed. Data on diagnostic value of clinical symptoms and US examinations for revealing ChDL are presented. ChDL without jaundice was detected in 47.4% of patients. Current diagnostic facilities in primary choledocholithiasis before the operation and intraoperative are discussed. After choledochotomy, if there are no contraindications, it is recommended to finish the operation by external drainage of bile ducts with the use of T-shaped drainage tube. If residual ChDL is detected, it would be reliably eliminated without surgery.

Abnormal sphincter of Oddi response to cholecystokinin in postcholecystectomy syndrome patients with irritable bowel syndrome. The irritable sphincter

Standard biliary manometry, including cholecystokinin (CCK) provocation, was performed on 42 consecutive patients (36 F, 6 M, median age 45 years) with postcholecystectomy syndrome (PCS) who had no evidence of organic disease but who had objective clinical features suggesting sphincter of Oddi dysfunction (SOD) (classes I and II). Patients were subdivided into those with (N = 14) and without (N = 28) irritable bowel syndrome (IBS) using a validated symptom questionnaire based on the modified Rome criteria. Resting sphincter of Oddi (SO) motor parameters (basal pressure, contractile amplitude and frequency, and proportion of retrograde contractions), the presence of abnormal manometry, and the presence of an abnormal response to CCK were compared in the two groups. No significant differences in resting parameters of SO motor activity between patients with and without IBS were observed, and abnormal biliary manometry as a whole was not more prevalent in either group (8/13 and 18/27, respectively). An abnormal response to CCK (failure of complete inhibition of phasic contractions), however, was demonstrated in five of 12 patients with IBS compared with only one of 23 patients without IBS (P = 0.01). In patients with postcholecystectomy SOD, an abnormal response of the SO to CCK thus appears to be an important feature of the subset of patients with concomitant IBS.