What is the role of surgery in the treatment of postcholecystectomy syndrome (PCS)?

Updated: Nov 28, 2018
  • Author: Steen W Jensen, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Answer

Like medical therapy, surgical therapy should be directed at the specific diagnosis. [15, 16] Surgery is indicated when an identifiable cause of PCS that is known to respond well to operative intervention has been established. The most commonly performed procedure is endoscopic retrograde cholangiopancreatography (ERCP), which can be both diagnostic and therapeutic. Exploratory surgery is a last resort in the patient who lacks a diagnosis and whose condition proves refractory to medical therapy.

In 1947, Womack suggested resection of scar and nerve tissue around the cystic duct stump, though this method is somewhat controversial. [1] Others suggested resection of neuroma, cystic duct remnant, sphincter dilation, sphincterotomy, sphincteroplasty, biliary bypass, common bile duct (CBD) exploration, and stone removal. With ERCP, most of these diagnoses would have been ruled out or treated, and the idea of amputation of neuroma was controversial.

Patients abusing alcohol or narcotics are especially difficult to manage, and exploratory surgery should be postponed until they have stopped abusing these drugs.

In a few patients, no causes are identifiable and exploration is unrevealing, but the condition may respond to sphincteroplasty, including the bile and pancreatic ducts. This group of patients is not yet identifiable preoperatively.

If, after a complete evaluation (including ERCP with sphincterotomy), a patient continues to experience debilitating, intermittent right-upper-quadrant pain, and no diagnosis is found, the procedure of choice after a normal exploratory laparotomy is transduodenal sphincteroplasty.

When postcholecystectomy syndrome (PCS) results from remnant cystic duct lithiasis (RCDL; ie, gallstones within the cystic duct after cholecystectomy), endoscopic therapy may suffice, but surgical excision of the RCDL may be necessary in some cases. [17]


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