[The consequences of cholecystectomy]. / Posledstviya kholetsistektomii (s kommentariem).

AIM: to analyze the consequences of cholecystectomy. MATERIAL AND METHODS: 348 patients were under observation within 10  years after cholecystectomy. Surgery for destructive and chronic cholecystitis was performed in 115 and 233 patients respectively. The consequences of cholecystectomy were assessed using bile acids level in blood plasma, stomach and duodenal pressure, pancreatic and stomach changes. RESULTS AND DISCUSSION: It was established that lithocholic, deoxycholic, taurodeoxycholic acids were increased by 44% within 10 years after surgery. At the same time glycocholic and tauroursodeoxycholic acids were decreased by 21.5% in 5 years after surgery. Bile acids level changes were associated with changes of stomach and duodenal pressure. The most pronounced disorders were observed in distal duodenum. There was more than 2.8-fold excess of normal pressure in this area. Duodenal hypertension was accompanied by pancreatic ducts enlargement in 9.5% of cases and increased echogenicity in 93% of cases. CONCLUSION: Changes of the level and proportion of blood plasma bile acids and hypertension in upper gastrointestinal tract are the most important in chronic pancreatitis pathogenesis after cholecystectomy. Such conditions occur within first 3 years after surgery.

[POSTCHOLECYSTECTOMY SYNDROME: CLASSIFICATION, THE RISK FACTORS, CRITERIA OF THE DIAGNOSIS ESTABLISHMENT, TREATMENT-DIAGNOSTIC ALGORITHM].

Own experience of surgical treatment of patients for postcholecystectomy syndrome (PCHES) in a 2010 - 2015 yrs period was enlighten. The PCHES modified classification was adduced, the immediate and remote results of the patients' treatment were analyzed, technical aspects and peculiarities of performance of some operative interventions, the risk factors for the PCHES occurrence were analyzed.

Belching After Biliary Pancreatitis and Laparoscopic Cholecystectomy.

INTRODUCTION: Belching is often reported symptom. It is rarely an isolated disorder and mainly occurs within various gastroduodenal diseases. AIM: The aim is to show the great breadth of clinical symptoms of postcholecystectomy syndrome which should have a multidisciplinary therapeutic approach taking into account all aspects of patient's life. CASE REPORT: We report a case of excessive belching within postcholecystectomy syndrome which disturbs the general psycho-physical condition of the patient, with symptoms of depression and anxiety, and social isolation, which significantly reduces the quality of his life.

[Diagnosis of sphincter of Oddi dysfunction in patients with postcholecystectomy syndrome from hepatobiliary scintigraphic findings].

OBJECTIVE: to diagnose and estimate the clinical value of postcholecystectomy sphincter of Oddi dysfunction in patients. MATERIAL AND METHODS: Examinations were made in 100 postcholecystectomy patients without signs of cholestasis; of them 14 postpapillotomy patients formed a comparison group. Hepatobiliary scintigraphy using the radiotracer 99mTC-bromeside was performed for 90 minutes with cholagogue breakfast at 45 minutes. Common bile duct and duodenal functions and duodenogastric reflux (DGR) were evaluated comparing them with clinical, laboratory, and instrumental findings. RESULTS: Two patient groups were identified according to bile outflow changes. In Group I consisting of 20 (23.2%) patients, the time of maximum accumulation (Tmax) of the radiopharmaceutical in the projection of the choledochus coincided with that in the cholagogue test (46.0 1.8 min) and in Group 2 including 66 (76.8%) patients that was shorter than in the cholagogue test (32.9 +/- 6.8 min) (p<0.05). In Group 2, Tmax was similar to that in the comparison group (30.9 +/- 7.5 min; p > 0.05) and there was no significant difference in intestinal imaging time (18.6 +/- 6.0 min versus 17.6 +/- 0.8) either, which could be indicative of sphincter of Oddi dysfunction. Diarrhea was observed in 73% of the patients with sphincter of Oddi dysfunction and in 86% of the patients in the comparison group versus 10% of the patients with normal bile passage (p<0.01). Statistical data processing showed a correlation of the indicators of sphincter of Oddi dysfunction with those of duodenal evacuator function (r = 0.57; p < 0.0005) and DGR (r = 0.74; p < 0.009). CONCLUSION: Postcholecystectomy sphincter of Oddi dysfunction assumes the greatest clinical value in patients with duodenal motor-evacuator dysfunction, which should be hepatobiliamy scintigraphic, kept in mind when choossphincter of Oddi dysfunction ing a treatment policy.

[Cholelithiasis: complications and rehabilitation].

The results of laparoscopic cholecystectomy, conducted in 71 patients, suffering cholelithiasis, were analyzed. In early postoperative period an acute cholangitis have occurred in 2 (2.8%) patients, an acute pancreatitis--in 1 (1.4%), postoperative infiltrate--in 14(19.7%), suppuration of postoperative cicatrix--in 6 (8.4%); late compli- cations as a kind of postcholecystectomy syndrome was observed in 29 (40.8%) patients, and abdominal hernia--in 3 (4.2%).

[Effectiveness of duspatalin therapy in the treatment and prevention of post-cholecystectomy syndrome].

Results of evaluation of the efficiency of myotropic spasmolytic Duspatalin during long-term therapy and preventive treatment of functional post-cholecystectomy syndrome are presented. The influence of the treatment on manifestations of clinical symptoms, quality of a life estimated based on a visual-analog scale, and intestinal microbiocenosis (changes in the activity of short-chain fatty acids) are discussed.

[Morphological features and esophago-gastroduodenal zone microbiocenose in patients with syndrome postcholecystectomic syndrome].

Endoscopical and histological features of oesophagogastroduodenal zone, parameters of pH-metry and electrogastroenterography, qualitative and quantitative characteristics of microbiocenosis were studied in 80 female persons with postcholecystectomy syndrome more then a year after cholecystectomy. In the presence of duodenogastral reflux the most natural is the combination of distal oesophagitis, antral atrophic gastritis and duodenitis, accompanied with low level of gastric acidity, gastric hypokinesis and duodenal dyskinesis, dysbacteriosis of mucosal microflora with its quantitative increase and appearance of bacteria with expressed pathogenicity non-typical for this biotope. These data should be taken into consideration for determination of pre- and postoperative treatment tactics for patients with gallstones.

[The results of different types of cholecystectomy in elderly patients].

Treatment results of 1048 elderly patients, operated on the cholelithiasis, were analyzed. The group of minilaparotomic access cholecystectomy numbered 488 (46,6%) patients; the second group consisted of 560 (53,4%) patients, who had the traditional operation. All patients were operated on in a single hospital during 1998-2008 yy. The cholecystectomy from minilaparotomic access proved to be less traumatic and preferable for elderly patients. The rate of postoperative morbidity was 5,7%, mortality - 0,2%. The procedure, though, is subjected to the experienced surgeons.

[Clinique--pathogenetic features of postcholecystectomy syndrome in children].

UNLABELLED: Years of experience observing children with GSD made possible to determine the clinical course and to clarify some of mechanisms of postcholecystectomical syndrome formation in children. Material and methods. There were observed 148 children who underwent cholecystectomy at the age of 3 to 15 years. There were 44 boys and 104 girls. Diagnosis refined was conducting by ultrasonography, magnetic resonance imaging. Degree of biliary insufficiency was assessed based on dynamic of gepatobilliarscintigraphy. The clinical picture of disease was assessed according to age and sex of the child. RESULTS: We described the clinical course and pathogenetic mechanisms of postcholecystectomical syndrome in children in the age aspect. Based on the results of our research, were found ways of correction of postcholecystectomical syndrome in children with cholelithiasis.

[Post-cholecystectomy syndrome: the modern view of the problem].

The authors summarize and systematize literature data and their own observations concerning post-cholecystectomy syndrome (PCES), the reasons for and the mechanisms of its development, its clinical variants etc. The authors suggest the following PCES forms should be distinguished: functional ("egenuine") forms, which develop due to gall bladder removal and the loss of its functions, and organic ("conditional") PCES forms, which develop as a consequence ofaflawy surgery and/or preoperative complications of chronic calculous cholecystitis, which dominate in the postoperative clinical picture and are mistakenly considered cholecystectomy consequences. An original operational classification of PCES is adduced; possibilities provided by contemporary instrumental and laboratory techniques of differential diagnostics are considered; differential treatment and prophylaxis of PCES are described.

Acalculous biliary pain: new concepts for an old entity.

Biliary pain is commonly reported in household surveys with the presumed cause being gallstones. When gallstones are absent or other abnormalities as a potential cause of similar pain do not exist, a different approach is necessary. Although trans-abdominal ultrasound can detect stones down to 3-5 mm, the advent of endoscopic ultrasound provides an even better definition for microlithiasis of < 3 mm. Duodenal aspiration of bile can further detect cholesterol microlithiasis or bilirubin granules, another potential source of biliary-type pain and perhaps even pancreatitis. Only in this way can acalculous gallbladder disease be clearly defined. The percentage of cholecystokinin-stimulated gallbladder emptying has been reputed to be the most sensitive diagnostic test for 'biliary dyskinesia', but abnormality of gallbladder emptying can be due to a smooth muscle defect of the gallbladder itself or heightened tone in the sphincter of Oddi. The value of surgical intervention has not been clearly established. The advent of laparoscopic cholecystectomy, however, has increased the number of patients with acalculous biliary disease who undergo surgery. Surgery is best done using impaired gallbladder emptying as the criterion for operation with improved outcome. Often, following cholecystectomy, biliary pain does not resolve the so-called 'post cholecystectomy syndrome'. Absence of the gallbladder as a pressure reservoir leaves the sphincter of Oddi as the prime determinant of bile duct pressure. Sphincter of Oddi dysfunction also exists in patients with an intact biliary tract and may become evident following cholecystectomy. Biliary manometry has clarified who might benefit from sphincterotomy. Choledochoscintigraphy is a non-invasive preliminary test. Advent of visceral hypersensitivity and better definition of this entity has shown, that in some of these patients with type III sphincter of Oddi, dysfunction appears to reside in duodenal hyperalgesia. It is clear that improved criteria are required to perform gallbladder emptying and better techniques to detect visceral hypersensitivity. Nonetheless, functional biliary pain in the absence of gallstone disease is a definite entity and a challenge for clinicians.

Sphincter of Oddi dysfunction.

Biliary-like pain alone, or associated with a transient increase in liver or pancreatic enzyme, may be the clinical manifestations of sphincter of Oddi dysfunction. Since it is not always possible to dissociate functional conditions from subtle structural changes, the term sphincter of Oddi dysfunction is used to define motility abnormalities caused by 'sphincter of Oddi stenosis' and 'sphincter of Oddi dyskinesia'. Both sphincter of Oddi stenosis and sphincter of Oddi dyskinesia may account for obstruction to flow through the sphincter of Oddi and may thus induce retention of bile in the biliary tree and pancreatic juice in the pancreatic duct. Most of the clinical information concerning sphincter of Oddi dysfunction refers to post-cholecystectomy patients who have been arbitrarily classified according to clinical presentation, laboratory results and endoscopic retrograde cholangiopancreatography findings in: (a) biliary type I, (b) biliary type II, and (c) biliary type III. Prevalence of biliary-type of pain has been reported to vary from 1 to 1.5% in unselected postcholecystectomy people, to 14% in a selected group of patients complaining of postcholecystectomy symptoms. The frequency of sphincter of Oddi dysfunction, as shown by manometry, differs in the different clinical subgroups: 65-95% in biliary group I, mainly due to sphincter of Oddi stenosis; 50-63% in biliary type II, and 12-28% in biliary type III. In patients with idiopathic recurrent pancreatitis, sphincter of Oddi dysfunction varies from 39 to 90%. Diagnostic work-up of postcholecystectomy patients for suspected sphincter of Oddi dysfunction includes liver biochemistry and pancreatic enzymes, plus negative findings of structural abnormalities. Usually, this would include transabdominal ultrasound and endoscopic retrograde cholangiopancreatography. Depending on the available resources, endoscopic ultrasound and magnetic resonance cholangiography may precede endoscopic retrograde cholangiopancreatography in specific clinical conditions. Quantitative evaluation of bile transit from the hepatic hilum to the duodenum at choledochoscintigraphy appears valuable in the decision to undertake sphincter of Oddi manometry or to treat. Sphincterotomy is the standard treatment for sphincter of Oddi dysfunction. In biliary type I patients, the indication for endoscopic sphincterotomy is straightforward without the need of any additional investigation. Slow bile transit in biliary type II is an indication to undergo endoscopic sphincterotomy without sphincter of Oddi manometry. Slow bile transit in biliary type III patients is an indication to perform sphincter of Oddi manometry. Diagnostic work-up of patients with gallbladder in situ is part of the same diagnostic algorithm that has initially excluded the presence of a gallbladder dysfunction.

[Correction of the gastric and duodenal motility by laser puncture in pancreatobiliary diseases]. / Korrektsiia motoriki zheludka i dvenadtsatiperstnoi kishki pri zabolevaniiakh organov pankreatobiliarnoi zony metodom lazeropunktury.

96.7 percent of patients with affections of organs of the pancreatobiliary zone displayed motor function disorders of upper portions of the alimentary canal (AC). A characteristic sign of the pathological process in pancreatobiliary organs is decreased frequency of recordable biopotentials and qualitative changes in electrogastrogrames. Changes in qualitative characteristics of the electrogastrogram are clearly related to increase in the intraduodenal pressure recordable with the aid of the "open catheter" technique. Laseropuncture is an effective supplementary method for correction of motility disorders in the upper portions of AC in those patients presenting with affections of the pancreatobiliary organs.

Bile duct crystals do not contribute to sphincter of Oddi dysfunction.

BACKGROUND: Microlithiasis has been proposed as a cause of both occult gallbladder disease and of idiopathic pancreatitis. Theoretically, microlithiasis could also cause postcholecystectomy pain by causing temporary biliary obstruction and may be more common in patients with sphincter of Oddi dysfunction. The frequency of crystals in bile duct aspirates was assessed from patients with symptoms after cholecystectomy with and without elevated baseline sphincter of Oddi pressures. METHODS: A prospective analysis was performed on all patients with recurrent biliary pain after cholecystectomy who presented for ERCP and manometry between January 1998 and June 2000. All patients had aspirates obtained from the common bile duct for crystal analysis by using the aspirating port of the manometry catheter before the injection of contrast. Four to 20 mL of bile was examined by microscopy for both cholesterol and bilirubinate crystals. RESULTS: Sixty patients (83% women, mean age 44 years) were studied. Thirty-five had normal baseline biliary sphincter pressures and 25 elevated biliary baseline sphincter pressures (>40 mm Hg). Two patients in the normal pressure group and 1 in the elevated pressure group had cholesterol crystals present in their aspirate. No patient had bilirubinate crystals present. A 5% frequency of microlithiasis was identified overall. CONCLUSIONS: Bile duct crystals occur infrequently in patients with symptoms after cholecystectomy and are found in patients with normal and abnormal biliary sphincter manometry. This study suggests that the presence of bile duct crystals, or microlithiasis, does not play a role in sphincter of Oddi dysfunction.

Efficacy of biliary scintigraphy in suspected sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) can pose diagnostic challenges for the physician. SOD is classified into types I, II, and III, but clinical outcome after sphincterotomy for suspected types II and III SOD has been unpredictable. Therefore, accurate diagnosis of types II and III SOD is important because of the increased risk of sphincterotomy in patients with SOD. Endoscopic sphincter of Oddi manometry (ESOM) is the gold standard for diagnosis of SOD; however, it is associated with significant morbidity and is not an appropriate screening test. Quantitative hepatobiliary scintigraphy (QHBS) has demonstrated good sensitivity as a screening test for SOD in patients following cholecystectomy; however, studies using this methodology are criticized for poor design and patient selection. Recent publications address these criticisms and provide evidence that QHBS and ESOM are comparable diagnostic tools after exclusion of organic biliary obstruction. QHBS can effectively replace invasive ESOM in the diagnostic algorithm of SOD.

Pain associated with phase III of the duodenal migrating motor complex in patients with postcholecystectomy biliary dyskinesia.

BACKGROUND: Correlation between various gastrointestinal events and particular aspects of the migrating motor complex has been reported. This study correlates postcholecystectomy pain to variations in biliary pressure associated with the duodenal motor cycle. METHODS: In 18 patients with postcholecystectomy pain and 10 control subjects, biliary and duodenal pressures were recorded simultaneously with microtransducers. After recording a spontaneous cycle, morphine was administered to induce a premature phase III and spasm of the sphincter of Oddi, and then cerulein was administered to stop the spasm. RESULTS: Transient but significant elevations of biliary pressure occurred at duodenal phase III in both groups, but a greater percentage of the patients developed pain during phase III (89% vs. 20%, p<0.01). Morphine produced premature phase III and biliary pressure elevation, which were accompanied by pain more frequently in the patients than in the control subjects (78% vs. 30%, p<0.05). Biliary pressure dropped after the cerulein injection, relieving the pain in 13 of 14 patients and in 2 of 3 control subjects who had morphine-induced pain. The phase III-related pain was relieved by endoscopic sphincterotomy in 14 of 15 patients. CONCLUSIONS: The cyclic elevation of biliary pressure in coordination with phase III of the duodenal motor cycle may contribute to the development of pain in patients with postcholecystectomy biliary dyskinesia.