Frequently the removal of the gallbladder is followed by acute symptoms identical to those which existed prior to operation. This postoperative symptom complex so characteristic of gallbladder disease is called the postcholecystectomy syndrome.
The postcholecystectomy syndrome may resemble cholecystitis and cholelithiasis in all their varied clinical manifestations and it may simulate many of the physical findings. The acute symptoms sometimes occurring during the convalescent period and most frequently noted during the first two years may be heralded by agonizing colic confined to the upper half of the abdomen, often radiating to either shoulder or the interscapular region. These attacks are commonly accompanied by nausea and vomiting, and are often associated with transient periods of mild jaundice, pruritus, and occasionally intermittent fever and chills. Physical examination may reveal abdominal soreness and occasionally a tinge of icterus.
Hellstrom,6 reporting one thousand and forty-one cases in which cholecystectomy had been done, stated that about 30 per cent of the patients complained of upper abdominal pain and distressing pressure. The symptoms were similar in nature to the colicky attacks described prior to cholecystectomy. In only nine of the cases were the episodes due- to residual ductal calculi, and in a few of the patients the attacks terminated in an acute pancreatitis. However, in the majority of cases Hellstrom offered no explanation which would account for the occurrence of the postcholecystectomy colic.
Doubilet,7 in the Surgical Clinic of The Mount Sinai Hospital, personally interviewed two hundred and fifty-three patients following operations for gallbladder disease and saw them at regular intervals during periods varying from one to seven years. The end results are summarized in Table I. Practically 40 per cent of all patients who were followed suffered from postoperative symptoms, either temporary or permanent. The majority of this group described the acute episodes as resembling those which had existed prior to operation and in some cases the attacks were frequent and severe enough to require sedation. The pains were of two main types. In the larger group, seventy-eight patients stated that the intense postprandial pain lasted from five minutes to two hours and occasionally radiated to the back. In a smaller group comprising twenty-four patients the pain which lasted from two to twenty-four hours radiated from the left upper quadrant to the shoulders. It was frequently accompanied by persistent abdominal soreness and in two cases an acute pancreatitis developed. In our experience these symptoms might follow the surgical removal of any gallbladder regardless of its pathologic lesions. The postcholecystectomy syndrome was most frequent in those cases characterized by definite colic prior to operation and in which functional disturbances were demonstrated by cholecystography, but in which surgical exploration revealed the absence of pathologic lesions of the gallbladder or the presence of a noncalculous cholecystitis. It seemed less frequent in cases of calculous cholecystitis. The syndrome was relatively rare when a fibrosed functionless gallbladder and dilated common duct were present.
The etiology of the postcholecystectomy syndrome may usually be attributed to a dyskinesia of the sphincter mechanism. This sphincter spasm may be stimulated either by local causes or by intrabiliary factors such as recurrent or residual calculosis of the cystic or common bile duct, partial traumatic strictures of the choledochus, cholangitis or pancreatitis. In some cases the dyssynergia may be initiated by psychic disturbances or by glandular dyscrasias, and in others it may be the result of a spastic colon. The significance and importance of biliary dyskinesia has been thoroughly reviewed by Ivy, Goldman and Sandblom, 8’9 Hill,’0 and Bergh and Layne.” It will only be necessary here to consider certain fundamental anatomic, physiologic and pathologic data which are concerned in the mechanism and production of most cases of postcholecystectomy syndrome. The anatomy of the periampullary region of the duodenum has been extensively investigated by Letulle and Nathan-Larrier,12 Giordano and Mann,’3 and others, and has recently been examined from an embryologic standpoint by Boyden and his associates.14’1 (Fig. i) The latter have identified longitudinal fasciculi which probably served to erect the papilla and aid in
the ejection of bile, a sphincter of the pancreatic duct, a definite sphincter at the terminal end of the choledochus, and in addition a sphincter
of the ampulla which was found in about one-sixth of their dissections. The contraction of this muscle, while it prevents the flow of secretions into the duodenum, converts the choledochus and the pancreatic duct into one canal so that bile may pass into the pancreatic duct and pancreatic secretions may pass into the common bile duct.
Colp, R. (1944). The Postcholecystectomy Syndrome and Its Treatment. Bulletin of the New York Academy of Medicine, 20(4), 203–219.