How is surgery performed for 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

After workup, the patient should be made safe for an operation, and the planned operation should be safe for the patient. The operation should be structured to follow a logical and systematic course with attention to detail and careful handling of tissues, especially those of the biliary tract.

The endoscopist should be experienced in evaluating this type of patient, and the surgeon should be experienced in operating on them. A skilled assistant should also be invited, and the radiologist and endoscopist involved in the case should be available for consultation. The patient should be the first and only individual undergoing surgery in the morning. A fresh team in the operating room is helpful in a potentially long and tedious case.

After exploration and lysis of adhesions, intraoperative cholangiography (IOC) should be performed. The only circumstance in which IOC may be omitted is when a nonbiliary source is identified and a high-quality preoperative cholangiogram is available (eg, from ERCP).

Most authorities agree that sphincteroplasty and septoplasty between the CBD and the pancreatic duct should be performed unless the head of the pancreas is hard, fibrotic, or indurated from chronic pancreatitis. In this situation, choledochoduodenostomy may prove more effective. Sphincteroplasty requires a generous right subcostal incision and mobilization of the hepatic flexure of the colon and the duodenum.

The portal structures are identified, along with the cystic duct stump. When possible, IOC should be performed through the stump. Choledochoscopy may also be helpful if a stone or potentially malignant stricture was identified. This can also be accomplished via the cystic duct stump. Once the stump is no longer needed, it is ligated with absorbable suture within 5 mm of the CBD junction. If the stump is not used, a T-tube should be placed through the choledochotomy when it is done.

A short duodenotomy is made, centered over the ampulla, and fine silk stay sutures are placed. A small biliary catheter should be placed in either an antegrade or a retrograde fashion.

With 12 o’clock representing cephalad and 9 o’clock posterior, a 3- to 5-mm incision is made at 11 o’clock through the ampulla over the catheter. Fine monofilament absorbable sutures are placed to approximate the duodenal and CBD mucosa. Placement should continue along the catheter for 2-3 cm, using fine Potts scissors. Lachrymal probes can be used to ensure that the pancreatic duct is not ligated.

Secretin (1-2 units intravenously) may be administered to help identify the location of the pancreatic duct. A septoplasty is then carried out in a similar fashion for approximately 1 cm. The result should be the easy passage of a 5-mm probe into the CBD and of a 2-mm probe into the pancreatic duct. Biopsy specimens may be taken as necessary.

The duodenum is closed in two layers. A T-tube is left whenever a choledochotomy is created. Postoperative care should be appropriate for the patient and the operation that was performed.


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