Cause Of Post-cholecystectomy Syndrome Research Articles

Frequency of Post-Cholecystectomy Syndrome Among Patients Undergoing Cholecystectomy: A Teaching Hospital Experience

Background and Objectives: Post-cholecystectomy syndrome is defined as upper abdominal pain or dyspepsia that persists after the cholecystectomy. Some studies show its incidence is about 40%. This study aims to find out the frequency of early post-cholecystectomy syndrome at our hospital and its possible cause.Methods: It was an observational study conducted at POF Hospital Wah Cantt from January 2018 to January 2022. 505 patients who underwent cholecystectomy were included in this study to find the incidence and cause of post-cholecystectomy syndrome. All the data were noted in a predesigned proforma and entered in SPSS version 24.0.Results: Out of 505, 59 patients were diagnosed as cases of post cholecystectomy syndrome with an incidence of 11.68%. 40(67.7%) were female, 19(32.2%) were male. The mean age of the patient was 38.43±8years. In 36(61%) patients, no cause of pain was found. In 12(20%) patients the cause was acid- peptic diseases. Three(5%) patients have CBD stones, 2(3.3%) patients have the remnant of the gallbladder, 2(3.3%) patients had a fluid collection, 2(3.3%) patient had pancreatitis, 1(1.6%) patient had scar pain (hypertrophic scar) and 1(1.6%) patient had periampullary growth.Conclusion: The incidence of post-cholecystectomy syndrome is significant. Any patient presenting with pain postoperatively should be examined and thoroughly investigated for possible treatable causes.Keywords: Post-cholecystectomy syndrome, Acid peptic diseases, jaundice, laparoscopic cholecystectomy.

Post-cholecystectomy syndrome: A cohort study from a single private tertiary center

ObjectivesAlthough post-cholecystectomy syndrome (PCS) is a well-recognized complication, there are few reports arising from KSA. The effect of sleeve gastrectomy or endoscopic retrograde cholangiopancreatography (ERCP) stenting on the development of PCS is unknown. We aimed to measure the possible factors affecting the development of PCS, such as symptom duration, comorbidities, previous bariatric surgery, ERCP stent insertion, surgical intervention, conversion to open surgery and complication rate. MethodsThis was a prospective cohort and observational study conducted at a single, private tertiary center. We included 167 patients who underwent surgery for gallbladder disease between October 2019 and June 2020. The patients were classified into two groups according to their PCS status (PCS+ vs. PCS−). ResultsThirty-nine patients were PCS+ (23.3%). There was no significant difference between the two groups with regards to age, gender, BMI, ASA score, smoking, comorbidities, duration of symptoms, previous bariatric surgery, ERCP, stent insertion or sphincterotomy. Chronic cholecystitis was the predominant histopathology in 83% (139/167) of patients. The most frequent causes of PCS included biliary system dysfunction, bile salt-induced diarrhea, gastritis, gastroesophageal reflux disease, and retained stones. Overall, 71.8% (28/39) of patients had incident PCS; the remaining patients had persistent PCS. ConclusionsPCS is a neglected complication that was observed in 25% of patients mainly in the first year. Surgeon awareness can assist with patient diagnosis, preoperative selection and education. Furthermore, the history of ERCP stenting, sphincterotomy, or sleeve gastrectomy seems to be unrelated to PCS development.

Role of 99m Tc-Mebrofenin Hepatobiliary Scintigraphy in the Diagnosis of Post Cholecystectomy Syndrome.

Background Huge variation in the prevalence of post cholecystectomy syndrome (PCS) is because PCS can include a wide variety of disorders that can be both related and unrelated to cholecystectomy. Hepatobiliary scintigraphy (HBS) is a noninvasive nuclear medicine scan that can evaluate a delay in the transit of bile from the hepatic hilum to the duodenum using a radiotracer 99m Tc-Mebrofenin that can be associated with a functional ampullary obstruction. The aim of this study was to assess the role of 99m Tc-Mebrofenin HBS in the detection of the cause of PCS among the patients undergoing cholecystectomy. Methods Twenty-one patients who presented with PCS from September 2018 to February 2020 were included in the study. These patients were characterized based on history, examination, liver function test, and abdominal ultrasound. Sphincter of Oddi dysfunction (SOD) was diagnosed using the Rome 3 criteria and the Milwaukee classification. Magnetic resonance cholangiopancreatography (MRCP) and upper gastrointestinal endoscopy and biopsy were done when indicated, to establish the diagnosis. These patients were further subjected to 99m Tc-Mebrofenin HBS, and the findings were analyzed. Results The most common symptom in PCS was biliary pain occurring in 85.7% of the patients. The average time of presentation since surgery was 1.9 years. The most common cause of PCS was SOD, occurring in 52.3% of the patients, followed by benign biliary stricture occurring in 23.8% of the patients. The mean bile duct (common bile duct) visualization time in patients with PCS was 25.2 minutes, the mean duodenal visualization time was 38.2 minutes, and the mean jejunal visualization time was 60.5 minutes. The mean bile duct to duodenum transit time was 12.7 minutes, while the mean bile duct to jejunum transit time was 30.1 minutes. HBS showed consistent findings with the final diagnosis made by other diagnostic modalities (clinical criteria/MRCP/intraoperative findings) in 80.9% of the patients. Conclusion 99m Tc-Mebrofenin HBS has a significant role in the evaluation of PCS.

Post-cholecystectomy syndrome: a retrospective study analysing the associated demographics, aetiology, and healthcare utilization.

Post-cholecystectomy syndrome (PCS) is a group of heterogeneous signs and symptoms, predominately consisting of right upper quadrant abdominal pain, dyspepsia, and/or jaundice, manifesting after undergoing a cholecystectomy. According to some studies, as many as 40% of post-cholecystectomy patients are in fact, affected by this syndrome. This study aims to determine the demographics, aetiology, average length of hospital stay, and health care burden associated with PCS. We queried the National Inpatient Sample (NIS) database to determine inpatient admissions of PCS between 2011 and 2014 using the ICD-9 primary diagnosis code 576.0. From 2011 to 2014, the number of inpatient admissions with a principal diagnosis of PCS totally 275. The average length of hospital stay was 4.28±4.28, 3.42±2.73, 3.74±1.84, and 3.79±2.78 days in 2011, 2012, 2013, and 2014, respectively. The total yearly charges were $32,079±$24,697, $27,019±$22,633, $34,898.21±$24,408, and $35,204±$32,951 in 2011, 2012, 2013, and 2014, respectively. Notably, the primary cause of PCS in our patient sample between the year 2011 and 2014, was biliary duct dysfunction, followed by Peptic ulcer disease. In conclusion, there is a strong need to examine for and treat the underlying aetiology when approaching a post-cholecystectomy patient. We found that longer hospital stays, were associated with a greater health care burden, and visa versa. Furthermore, our findings help identify at-risk populations which can contribute to improving surveillance of this costly disease.

Clinical patterns and causes of post-cholecystectomy syndrome

Post-cholecystectomy syndrome is suspected when the patients complain about the persistent presence of pain in the right upper abdominal quadrant. Other symptoms might appear which are related to the gastrointestinal tract. These symptoms appear after performing cholecystectomy. The manifestations are usually similar to those experienced before the procedure. In this study, the aim to conduct a literature review to increase the knowledge and to explore facts related to the clinical patterns and causes of post-cholecystectomy syndrome. The most commonly reported cause of this syndrome is the prior development of an extra-biliary disorder, which includes many modalities as peptic ulcer, reflux esophagitis, chronic pancreatitis, irritable bowel syndrome, and biliary-related disorders. However, the etiology of postcholecystectomy is hugely variable across the different studies in the literature. Patients that develop postcholecystectomy syndrome usually present with non-specific gastrointestinal symptoms that may or may not be similar to the symptoms that were exhibited before conducting the surgery. Some of the common physiological changes that have been reported with postcholecystectomy syndrome include the disruption of cholecysto-antral reflex, the cholecystosphincter of oddi reflex, and the cholecysto-esophageal related reflexes. In addition, the development of other changes that can significantly affect the normal physiology of the gastrointestinal tract leads to the development of significant symptoms and clinical patterns.

Residual Gallbladder and Cystic Duct Stump Stone after Cholecystectomy: Laparoscopic Management.

Background: Cholecystectomy is the standard treatment for symptomatic gallstones, and the persistence of symptoms after surgery defines postcholecystectomy syndrome. Biliary causes of postcholecystectomy syndrome include subtotal cholecystectomy and remnant cystic duct stump stone; causes that are encountered with a low frequency, but which require diagnosis and provocative treatment. Laparoscopic management of such cases is recommended, but requires well-trained teams in laparoscopic surgery. Methods: This study is a retrospective analysis of patients who required surgical treatment for residual gallbladder and cystic duct stump stone after a cholecystectomy, hospitalized in the Surgery Department of Constanta County Hospital, who required completion of resection and were operated laparoscopically. Results: Between January 2010 and March 2020, 14 patients were hospitalized with residual gallbladder and cystic duct stump stone that required surgery. All patients underwent laparoscopic surgery. Symptomatology was dominated by recurrent biliary colic (50%). The period between the primary surgery and the surgery to complete the resection varied between 2-22 years. There were 4 cases of subtotal cholecystectomies, and 10 cases of remnant cystic duct stump stones. Intraoperative complications were encountered in only one case (7.14%), the number of days of hospitalization was on average 3 days. No patient showed any symptoms at 6-month postoperative follow-up. Conclusions: Postcholecystectomy syndrome is difficult to diagnose, symptomatic patients with remnant cystic duct stump stone/ subtotal cholecystectomy requiring surgery are difficult to manage. Laparoscopic surgery is preferred for the benefits that laparoscopic surgery brings, but requires an experienced surgeon in advanced laparoscopic techniques.

Iatrogenia as a cause of postcholecystectomy syndrome

Objective. To analyze the most frequent diagnostic, tactical and technical errors of young doctors, leading to postcholecystectomy syndrome.
 Materials and methods. The analysis was based on the clinical material of 87 patients from the Surgical Department of Regional Clinical Hospital №1 and City Clinical Hospital №2 of Izhevsk regarding reconstructive and restorative surgeries on the biliary tract for the last 40 years (19782018).
 Results. The reasons, causing iatrogenic injuries of the bile ducts during cholecystectomy, are diagnostic, tactical, technical. Diagnostic errors are more often associated with inadequate diagnosis of cholelithiasis and cholecystitis (underestimation of history, complaints, clinical picture of the disease and its complications; failure or impossibility of FGDS; insufficient topical diagnosis while ultrasound investigation of the biliary tract and abdominal organs). Tactical errors in surgeries on the gallbladder include: overly expectant tactics, incorrect choice of surgical approach and method of anesthesia, lack of experience of the surgeon, inadequate revision of the biliary tract during surgery, refusal from surgical cholangiography and external drainage of the choledoch in case of doubtful patency of the bile duct. Technical reasons are specific features of the anatomy of the extrahepatic biliary tract, factors complicating the surgery, violation of surgical technique when performing an operation on the bile duct.
 Conclusions. Correct and timely diagnosis of bile diseases as well as qualified technique of surgical intervention will minimize the development of post-cholecystectomy syndrome and other iatrogenic complications.

1418 A Troublesome Remnant

INTRODUCTION: Postcholecystectomy syndrome (PCS) is the persistence of symptoms of biliary colic after cholecystectomy. Although PCS is relatively common with multiple etiologies, a remnant cystic duct is a rare etiology accounting for only 2.5% of cases. Mirizzi's syndrome is a rare cause of PCS due to a remnant cystic duct stone. CASE DESCRIPTION/METHODS: A 34-year-old female with a history of choledocholithiasis status-post cholecystectomy 6 years prior presented with severe, constant, sharp right upper quadrant pain with nausea and vomiting for 1 day. She had abdominal tenderness with a negative Murphy sign. She was found to have elevated liver chemistries. Patient had two hospitalizations within the past year with similar presentations with the finding of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) on both occasions. Magnetic retrograde cholangiopancreatography (MRCP) showed a dilated, remnant cystic duct with filling defect indicative of obstruction caused by the stone. ERCP was done with removal of one stone followed by surgical resection of the remnant cystic duct with an endoluminal stone. DISCUSSION: The cystic duct typically measures 2-4 cm in length, and formation of stone in the structure leads to symptoms of dyspepsia, nausea, vomiting, and possibly jaundice. Cholecystectomy provides symptom relief to 85% of patients. After cholecystectomy, an incomplete surgery can leave a residual duct of greater than 1 cm in length, defined as a cystic duct or gallbladder remnant. Formation of calculi in this structure can lead to PCS. PCS can present as continuation of symptoms after the operation or after an interval of 2 days to 25 years after disease free period. PCS has been reported in 5 to 40% of patients post-cholecystectomy. Most common causes are extrabiliary, however, biliary etiologies are not uncommon. The incidence of PCS due to remnant cystic duct has been reported to be less than 2.5%. Identifying and promptly treating the underlying etiology are important to minimize morbidity. Cystic duct remnant stones may predispose a patient to postcholecystectomy Mirizzi's syndrome. While difficult to diagnose with different imaging studies, this can be effectively diagnosed with MRCP and treated with ERCP. One study showed that ERCP/MRCP failed to identify 2 out of 3 patients with a remnant cystic duct. While endoscopic therapy is an effective and safe alternative to surgery for postcholecystectomy Mirizzi's syndrome, surgical intervention is a definite treatment.

Postcholecystectomy syndrome from the position of surgeon and gastroenterologist

The article presents the results of treatment of 173 patients with postcholecystectomy syndrome and organic changes in the sphincter of Oddi and 140 patients with functional changes in the sphincter of Oddi. The main direction of therapeutic ma­nagement for organic causes of postcholecystectomy syndrome was maximum use of endoscopic methods and endosurgery in combination with modern therapeutic agents. When the functional changes in the sphincter of Oddi were detected, drug the­rapy was applied with a differentiated approach to the choice of drugs, depending on the prevalence of hypertonia or sphincter of Oddi dysfunction (mebeverine hydrochloride (duspatalin), itopride, trimebutine maleate (trimspa). For normalization of the physicochemical properties of bile and prevention of recurrent choledocholithiasis, ursodeoxycholic acid derivatives (Ursofalk) were used.

Remnant gallbladder stones: a rare cause of post-cholecystectomy syndrome

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Çetin D, Aday U, Çiyiltepe H, Gündeş E, Bozdağ E, Uzun O. Remnant gallbladder stones: a rare cause of post-cholecystectomy syndrome. Archives of Medical Science - Civilization Diseases. 2017;2(1):27-28. doi:10.5114/amscd.2017.66385. APA Çetin, D., Aday, U., Çiyiltepe, H., Gündeş, E., Bozdağ, E., & Uzun, O. (2017). Remnant gallbladder stones: a rare cause of post-cholecystectomy syndrome. Archives of Medical Science - Civilization Diseases, 2(1), 27-28. https://doi.org/10.5114/amscd.2017.66385 Chicago Çetin, Durmuş Ali, Ulaş Aday, Hüseyin Çiyiltepe, Ebubekir Gündeş, Emre Bozdağ, and Orhan Uzun. 2017. "Remnant gallbladder stones: a rare cause of post-cholecystectomy syndrome". Archives of Medical Science - Civilization Diseases 2 (1): 27-28. doi:10.5114/amscd.2017.66385. Harvard Çetin, D., Aday, U., Çiyiltepe, H., Gündeş, E., Bozdağ, E., and Uzun, O. (2017). Remnant gallbladder stones: a rare cause of post-cholecystectomy syndrome. Archives of Medical Science - Civilization Diseases, 2(1), pp.27-28. https://doi.org/10.5114/amscd.2017.66385 MLA Çetin, Durmuş Ali et al. "Remnant gallbladder stones: a rare cause of post-cholecystectomy syndrome." Archives of Medical Science - Civilization Diseases, vol. 2, no. 1, 2017, pp. 27-28. doi:10.5114/amscd.2017.66385. Vancouver Çetin D, Aday U, Çiyiltepe H, Gündeş E, Bozdağ E, Uzun O. Remnant gallbladder stones: a rare cause of post-cholecystectomy syndrome. Archives of Medical Science - Civilization Diseases. 2017;2(1):27-28. doi:10.5114/amscd.2017.66385.

Cystic duct remnant syndrome as a cause of post-cholecystectomy syndrome

Cystic duct remnant syndrome as a cause of post-cholecystectomy syndrome

Cystic duct remnant stone removal by endoscopic retrograde cholangiopancreatography

AbstractCystic duct remnant calculus (CDRC) is an important cause of postcholecystectomy syndrome.[1] Open assess cholecystectomy or laparoscopic cholecystectomy of the remnant duct is effective and considered to be preferred treatment. We report a case of 65-year-old female patient, a poor surgical candidate with CDRC who presented to us with biliary pain and obstructive jaundice secondary to common bile duct (CBD) stones, in whom CDRC was extracted during CBD clearance by endoscopic retrograde cholangiopancreatography.

The Laparoscopic Re-Exploration in the Management of the Gallbladder Remnant and the Cystic Duct Stump Calculi

The gallbladder remnant and the cystic duct stump calculi are uncommon causes of post-cholecystectomy syndrome. Re-exploration is usually needed in the cases where symptom persists. Very few case series and reports are available regarding laparoscopic re-exploration. To assess the safety and feasibility of Laparoscopic re-exploration in the cases of gallbladder remnant and cystic duct stump calculi leading to post cholecystectomy syndromes. In this study, laparoscopic re-explorations was done in 22 patients in which 17 patients had gallbladder remnant calculi and 5 had cystic duct stump calculi. The study considered parameters like the operative time, conversion rate, post-operative complications, post-operative hospital stay and mortality in these patients. The duration of study was 15 years and the data was retrospectively reviewed. The median operating time was 83 minutes (range 51 to 134 minutes). Only one patient had conversion to open surgery. In postoperative period two patients had bile leak. They were managed conservatively and leak subsided in 8 and 11 days respectively. One patient had postoperative bleeding not requiring blood transfusion. There was no major complication requiring further intervention and no mortality. Patients were discharged on median day 4 (range 2-11) after the surgery. Patients were followed up every 3 months for one year. However, out of these three patients did not turn up for follow-up. In expert hands laparoscopic re-exploration of the gallbladder remnant/cystic duct stump calculi can be performed within a reasonable operating time. The conversion to conventional re-exploration rate was very low with minimal post-operative complications and shorter hospital stay.

Evaluation of gastroesophageal reflux after laparoscopic cholecystectomy using combined impedance-pH monitoring.

Postoperative gastroesophageal reflux (GER) is one of the causes of post-cholecystectomy syndrome (PCS). Reports studying the effect of cholecystectomy on GER show conflicting results and only a few studies have used the more sensitive technique of combined impedance-pH monitoring. This study aimed to study the effect of laparoscopic cholestectomy on GER (acid/non-acid reflux) using impedance-pH monitoring. Sixty three consecutive patients of symptomatic cholelithiasis were evaluated. All patients underwent esophageal mannometry and 24-hour impedance-pH monitoring pre- and postoperatively. Frequency scale for the symptoms of GERD (FSSG) scoring was also done in each patient pre- and postoperatively. Out of sixty three patients, four developed symptoms of reflux postoperatively as detected by FSSG scoring. However, no significant changes were observed in lower esophageal sphincter (LES) characteristics, acid and non-acid reflux characteristics, total number of reflux episodes, or in the physical character of the refluxate following laparoscopic cholecystectomy. Significant decrease in the proximal acid reflux episodes was observed. The chemical characteristics (acid or non-acid reflux) as well as physical properties (liquid, gas or mixed) of reflux episodes remain unaffected following laparoscopic cholecystectomy. Cholecystectomy itself doesn't increases GER.

Surgical and Endoscopic Management of Remnant Cystic Duct Lithiasis After Cholecystectomy—a Case Series

IntroductionPostcholecystectomy syndrome (PCS) as a result of remnant cystic duct lithiasis (RCDL), or gallstones within the cystic duct after cholecystectomy, can cause persistent or recurrent symptoms after cholecystectomy. Study DesignA retrospective descriptive analysis was performed for all patients with RDCL at a single institution between 2001 and 2012. Details of presentation, diagnosis, and surgical and endoscopic treatments, and outcomes were collected and analyzed. ResultsTwelve patients with RCDL were identified. The interval between cholecystectomy to RCDL discovery was 34.2 months (range 0.5–168 months). On a standard liver enzyme panel, 75 % of patients had derangements in ≥1 indices, with the most common single laboratory test abnormality occurring in gamma-glutamyl transferase (GGT) (80 %). Eight operative reports noted that the cystic duct was noticeably dilated at the time of cholecystectomy. Two patients developed a cystic duct leak (Strasberg type A bile duct injury) postoperatively, which was managed nonoperatively. Six cases of RCDL required surgery, and six were managed endoscopically. ConclusionRCDL is a potential cause of postcholecystectomy syndrome, but the true incidence is unknown. Laboratory analysis and imaging are helpful in establishing the diagnosis of RCDL. Endoscopic therapy has a role in the treatment of RCDL, but surgical excision of the remnant cystic duct lithiasis may be required.

Symptomatic calculi in a remnant gallbladder: a rare cause of post-cholecystectomy syndrome and biliary pancreatitis

Biliary pain after cholecystectomy, known as post-cholecystectomy syndrome, is common and has a broad differential diagnosis. Here we present a case of biliary pancreatitis and intermittent biliary pain that was caused by a remnant gallbladder that contained calculi. A 45-year-old man presented for evaluation of abdominal pain. He had undergone cholecystectomy 2 years previously and described intermittent right upper quadrant pain and bloating associatedwith fatty meals, which had begun a few months after the cholecystectomy. He had been hospitalized 3 months before presentation to us with biliary pancreatitis. His physical examination was notable for mild right upper quadrant tenderness only. Laboratory results showed normal transaminases and bilirubin, but his alkaline phosphatase was minimally elevated. A computed tomography (CT) scan showed a small pouch with tiny calculi connected to the biliary tree (● Fig.1). This finding was confirmed by magnetic resonance cholangiopancreatography (MRCP) (● Fig.2). Endoscopic retrograde cholangiopancreatography (ERCP) was therefore performed. The cholangiogram showed a normal main bile duct, but calculi within a cystic structure that was connected to the biliary tree through the cystic duct, compatible with a gallbladder remnant (● Fig.3). A plastic stent was placed in the common bile duct (CBD) to facilitate intraoperative identification. The patient underwent resection of the gallbladder remnant 1 month later, following which he had no further symptoms. Calculi in the gallbladder or cystic duct remnant account for less than 2.5% of cases of post-cholecystectomy syndrome but must be considered in any patient with recurrent biliary pain after cholecystectomy [1]. Typically, symptoms arise if the cystic duct remnant contains stones and is longer than 1cm [2]. The cystic duct remnant dilates, giving the impression of a small gallbladder on imaging studies. Presentation can occur within weeks to months, but may be as long as decades after cholecystectomy. The condition can arise in those who have undergone either open or, more commonly, laparoscopic cholecystectomy [3,4]. Treatments include ERCP with sphincterotomy and possible stent placement to aid CBD drainage, with the definitive treatment being “re-cholecystectomy” [2], as in our patient. Successful extracorporeal shock-wave lithotripsy (ESWL) has also been reported [5]. While symptomatic calculi in a remnant gallbladder are rare, gastroenterologists should be aware of this diagnosis as endoscopic therapy may be indicated and surgical referral is usually warranted.

Cystic Duct Remnant Syndrome

Post-cholecystectomy syndrome (PCS) is a common manifestation in patients with cholecystectomy. The patients exhibit a heterogeneous group of symptoms, such as upper abdominal pain, vomiting, gastrointestinal disorders, jaundice, and dyspepsia. Choledocholithiasis, biliary dyskinesia, and dilation of cystic duct remnants are common causes of these symptoms. The symptoms can recur after a symptom-free period following cholecystectomy or they can persist after surgery. Ultrasonography, computed tomography (CT), and magnetic resonance imaging scan, which are non-invasive methods of imaging, have a high sensitivity in detecting the causes of PCS. We report a case of an 84-year-old lady who came to the Ultrasound Department with recurrent episodes of abdominal pain following cholecystectomy. The gray-scale sonography showed a dilated cystic structure, which was confirmed as the duct remnant in follow-up contrast-enhanced CT.

Biliary Causes of Postcholecystectomy Syndrome

The postcholecystectomy syndrome refers to the persistence of gastrointestinal symptoms after cholecystectomy; patients with this syndrome commonly seek treatment in the Emergency Department (ED). There are a multitude of biliary and non-biliary causes of postcholecystectomy syndrome. To review the biliary causes of postcholecystectomy syndrome and present a suggested diagnostic workup. A number of biliary causes are discussed, including choledocholithiasis, bile duct injury and biliary leaks, cystic duct and gallbladder remnants, sphincter of Oddi dysfunction, and biliary ascariasis. The ED workup should focus on differentiating biliary from non-biliary causes of the patient's symptoms. A right upper quadrant abdominal ultrasound, liver transaminases, alkaline phosphatase, and serum bilirubin are the tests most useful in the ED for making this distinction and determining the most appropriate treatment and disposition of the patient. Computed tomography may be of use in the initial post-operative period.

Postcholecystectomy Syndrome in the Laparoscopic Era

sWe describe the management of a cystic duct remnant calculus in a 45-year-old male patient who had undergone a laparoscopic cholecystectomy and re-presented with abdominal pain and jaundice. Magnetic resonance cholangiopancreatography was utilized to confirm the diagnosis of an impacted calculus within the remnant cystic duct along with several small retained common bile duct stones. Four sequential endoscopic procedures successfully removed all retained common bile duct calculi to alleviate the biliary obstruction; however, we were unable to treat the cystic duct remnant calculus endoscopically. The patient finally underwent successful laparoscopic excision of a 2.5-cm cystic duct remnant containing its impacted calculus. It remains unclear if cystic duct remnant calculi may become more prevalent as a cause of postcholecystectomy syndrome in future due to the large numbers of laparoscopic cholecystectomies performed in the past 2 decades.

Biliary Ascariasis as a Cause of Post-Cholecystectomy Syndrome in an Endemic Area

Background: Post-cholecystectomy syndrome encompasses numerous biliary, pancreatic and other entities. Biliary ascariasis is a common cause of adult biliary disease in an endemic area. Post-cholecystectomy biliary ascariasis, a cause of post- cholecystectomy syndrome although not yet defined is frequently seen in this part of the world. Method: Between Jan. 1990 and Jan. 2001, 104 cases of post-cholecystectomy biliary ascariasis were seen. Ultrasonography was found to be an excellent tool for diagnosing and monitoring of the worms inside the biliary tract. Endoscopic retrograde cholangiopancreatography had both diagnostic and therapeutic value. Results: The majority (68.2%) of patients responded to conservative treatment. Surgical treatment was advocated in 18.2%, which included 2 patients with liver abscesses. Endoscopic extraction of worms was successful in 48.2%. Conclusion: Post-cholecystectomy biliary ascariasis as a cause of post-cholecystectomy syndrome needs to be included in the list of causes for post-cholecystectomy syndrome. Although the majority of patients respond to conservative treatment but endoscopic extraction or surgical intervention may be needed. Routine deworming of patients undergoing cholecystectomy both preoperatively and postoperatively should be done in all patients in endemic areas of ascariasis. Although this entity is rare in Europe and United States, due to population migration and increased travel, it is necessary for surgeons in these countries to be aware of this condition.