Should We Perform Routine Upper Gastrointestinal Endoscopy Before Cholecystectomy?

As some patients have overlapping symptoms of biliary and gastroduodenal pathologies, no symptomatic relief can be achieved with cholecystectomy.¹ This condition is also known as postcholecystectomy syndrome. This term is used to describe a heterogeneous patient group with ongoing symptoms after cholecystectomy. It is not a real syndrome; the term is rather misleading. The cause of lack of complete relief after cholecystectomy is usually the wrong preoperative diagnosis of chronic cholecystitis. The only symptom entirely characteristic for chronic cholecystitis is biliary colic. The symptoms may persist without a change after the operation if cholecystectomy is performed with a view of relief of symptoms including dyspepsia or intolerance to fatty foods. The causes of the syndrome may include gastroduodenitis,² incomplete stone extraction, biliary stasis, inflammation, and strictures. A cystic canal remnant >1 cm, also called residual ductus, may predispose to symptoms of chronic postcholecystectomy.³

At our unit, patients scheduled for cholecystectomy with nonspecific symptoms undergo routine upper gastrointestinal (UGI) endoscopy. The aim of this study was to assess the effectiveness of UGI endoscopy in reducing the possibility of postcholecystectomy syndrome.

Materials and Method

This retrospective study was conducted between November 2011 and December 2012. A total of 194 cholecystectomy operations were performed.

In patients sampled for histopathologic examination in routine UGI endoscopy before cholecystectomy, screening for Helicobacter pylori and intestinal metaplasia was carried out with Giemsa stain and PAS–Alcian stain, respectively. Biopsy specimen is combined with urea and pH is measured (rapid urease test). H. pylori converts urea to ammonia (NH3 + CO2). Test is positive for H. pylori if pH of the medium becomes more alkaline, indicated by color change. Histology offers additional information on degree and pattern of inflammation.

Patients who did not undergo UGI endoscopy before operation were designated as Group A (n = 100), and those who underwent routine UGI endoscopy before operation were called Group B (n = 94).

Statistical Analysis

For statistical analyses, NCSS (Number Cruncher Statistical System), 2007&PASS (Power Analysis and Sample Size), and 2008 Statistical Software (Kaysville, Utah) software packages were used. Descriptive statistical methods (mean, SD, median, frequency, ratio) were used to describe study data, and Student's t test was used to compare normally distributed data. Yates' correction for continuity was used to compare qualitative data. The significance level was accepted as P < 0.01 and P < 0.05.

Results

Between November 2011 and December 2012, the study was conducted in 194 cases of which 23.2% (n = 45) were male, and 76.8% (n = 149) were female. The age range of the cases was 19 years to 86 years, and the mean age was 50.48 ± 14.38 years.

Of 94 patients who underwent routine endoscopy before operation, 39 (41.5%) were diagnosed with H. pylori positivity as a result of examination of histopathologic samples obtained from antrum. Thirty-one of these 39 patients were administered H. pylori eradication treatment. Seven (22.6%) of 31 patients undergoing H. pylori eradication during preoperative period had ongoing symptoms at the postoperative period. On the other hand, only 2 (25%) of 8 patients who did not undergo H. pylori eradication during the preoperative period had unremitting symptoms during the postoperative period (Fig. 1). Only three (3%) of 100 patients who did not receive UGI endoscopy during the preoperative period had unremitting symptoms during the postoperative period (Table 1).

View Figure

• Download as Powerpoint
• Download Figure

Table 1 Distribution of descriptive features

View Fullscreen

There were no significant differences between the groups with respect to mean age, gender, and rates of postcholecystectomy syndrome according to endoscopic status (P > 0.05) (Table 2).

Table 2 Assessment of age, gender, and postcholecystectomy measurements in terms of endoscopic status

View Fullscreen

A significant difference was detected between the groups with respect to mean age (P < 0.05) such that the H. pylori (−) group had a significantly higher mean age compared with H. pylori (+) cases. There were no significant differences between the groups in terms of gender (P > 0.05; Table 3).

Table 3 Assessment of demographic characteristics in cases that underwent endoscopy (n = 94)

View Fullscreen

Discussion and Conclusion

The results of our clinical trial suggest that there is no difference between patients who undergo routine UGI endoscopy at the preoperative period and patients who do not undergo such a procedure with respect to symptom persistence at postoperative period. The reason for this condition is probably the consideration of biliary colic as the sole absolute indication of cholecystectomy.

In our study, 22.6% of patients undergoing H. pylori eradication during the preoperative period had ongoing symptoms at the postoperative period. On the other hand, 25% of patients who did not undergo H. pylori eradication during the preoperative period had unremitting symptoms during the postoperative period. That means there is not a significant relationship between H. pylori eradication and postcholecystectomy syndrome. Caldwell et al reported that the number of patients with H. pylori infection increases from preoperatively to postcholecystectomy due to the association between cholecystectomy and the increase in the percentage time gastric pH.⁴

Ergim et al reported that gastroduodenitis was the most common cause of postcholecystectomy syndrome.² Another study pointed out that the symptoms commonly arise as a result of inadequate surgical measures (a residual choledochal stone, residues of cystic duct or gall bladder, an unnoticed malignancy, intrahepatic stones, biliary fistula, surgical trauma-induced biliary tree strictures, and Oddi's sphincter stenosis).⁵

The cause of the postcholecystectomy syndromes is not a single specific entity. In 5% of cases, postoperative symptoms may develop despite a robust cholecystectomy indication. This group represents the actual postcholecystectomy syndromes.

Literature data suggest that the rate of mild or severe postoperative symptoms (including dyspepsia and postprandial pressure sensation in epigastrium, severe epigastric pain accompanying jaundice, and cholangitis) is 4% to 40%.

Cystic duct lithiasis (CDL) is found frequently during cholecystectomy; CDL is often associated with preoperative pain, abnormal liver function tests, and choledocholithiasis. It can persist despite preoperative sphincterotomy. The search for and treatment of CDL should be routinely performed during cholecystectomy.⁶

A cystic duct remnant is defined as a residual duct >1 cm; it may predispose to chronic postcholecystectomy symptoms. The laparoscopic removal with complete cystic duct remnant excision is a definitive cure of chronic painful symptoms.³

Gallbladder remnant containing stones may be the cause of otherwise unexplained postcholecystectomy pain. Completion cholecystectomy offers a definitive treatment for any residual gallbladder remnant and can be performed laparoscopically.⁷

The therapeutic approach in patients with sphincter of Oddi (SO) dysfunction (SOD) aims to reduce the resistance to the flow of bile or pancreatic juice. Vardenafil inhibits the activity of phosphodiesterase type 5 (PDE–5), which degrades cyclic guanosine monophosphate (cGMP) and results in relaxation of smooth muscle. Although vardenafil inhibits SO motility in patients with suspected SOD and reduces basal SO pressure, it does not have significant adverse effects.⁸

Steffen reported a case of a metal clip as a nidus for formation of common bile duct stone 2 years after laparascopic cholecystectomy.⁹ Surgical nonabsorbable sutures can act as a nidus for symptomatic common bile duct (CBD) stones.¹⁰ However, migrated suture material per se, without stone formation and causing symptoms, has been reported in only 1 patient in the English-language literature, back in 1977.¹¹ Das reported the second case of suture material without stone formation in the common bile duct causing recurrent postcholecystectomy pain in 2010.¹²

In only 50% of cases an organic disorder is present.^5,13 Many patients with gastroparesis have had their gallbladders removed. Symptom profiles in patients with and without cholecystectomy differ: postcholecystectomy gastroparesis patients had more severe upper abdominal pain and retching and less severe constipation. These data suggest that prior cholecystectomy is associated with selected manifestations of gastroparesis.¹⁴

In conclusion, it is important to note that cholelithiasis is responsible for 85% of biliary diseases.¹⁵ Cholecystectomy is the most common operation performed in the biliary system, which may or may not be performed with evaluation of the common bile duct or UGI system. Postcholecystectomy syndrome develops in 3% to 5% of cases, and an organic etiology can be detected in only 50% of them. Therefore, as our study also suggested, it would be prudent to perform an UGI endoscopy in selected cases (cases having dyspepsia rather than biliary colic, the characteristic symptom of chronic cholecystitis; and a group of patients with more nonspecific symptoms, such as intolerance to fatty food) before cholecystectomy rather than routinely performing it in all patients.