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Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Background This study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones. Methods The records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES. Results All patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval. Conclusions ES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.

Gallstone disease in children is evolving, and for the previous 3 decades, the frequency for surgery has increased greatly. This is in part because of improved diagnostic modalities, but also changing pathology, an increased awareness of emerging comorbidities, such as childhood obesity, and other associated risk factors. This article outlines the pathophysiology, genetics, and predisposing factors for developing gallstones and includes a review of the literature on the current and more novel medical and surgical techniques to treat this interesting disease.

196 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 1 : 2012 . Lewin JS, Baugh RF, Baker SR. An objective method for prediction of tracheoesophageal speech production. J Speech Hear Disord 1987;52: 212-7. . Lewin JS, Bishop-Leone JK, Forman AD, et al. Further experience with Botox injection for tracheoesophageal speech failure. Head Neck 2001; 23:456-60. . List MA, D’Antonio LL, Cella DF, et al. The Performance Status Scale for Head and Neck Cancer Patients and the Functional Assessment of Cancer Therapy-Head and Neck Scale. A study of utility and validity. Cancer 1996; 77:2294-301. . Krause E, Hempel JM, Gurkov R. Botulinum toxin A prolongs functional durability of voice prostheses in laryngectomees with pharyngoesophageal spasm. Am J Otolaryngol 2009;30:371-5.

Unrecognized lithiasis of the cystic duct (CDL) may be responsible for post cholecystectomy. This retrospective study looked at the incidence of CDL during cholecystectomy, as well as the context of its occurrence; recommendations for a practical surgical approach are offered.Over a period of 30 months, 143 consecutive cholecystectomies (103 women, 40 men; mean age: 57 years) were performed by the same surgeon: 142 by laparoscopy, and one by laparotomy due to a history of previous gastrectomy. The cystic duct was always opened and milked upward in search of CDL before immediate clip occlusion or performance of cholangiography (106 times, 74.1%). In seven cases, cholangiography was impossible because the cystic duct was too narrow.There was no mortality. CDL was found in 21 cases (14.7%) and removed. This had not been identified by preoperative imaging (ultrasound or CT). Pain in the month preceding cholecystectomy occurred more frequently in cases of CDL (19/21[90.4%] vs 36/122 [29.5%]; P0.001). Similarly, liver function tests were more often abnormal with CDL (10/21 [47.6%] vs 30/122 [24.5%]; P0.05). However, neither jaundice nor gallbladder inflammation was predictive of CDL in this study. Echoendoscopy (EUS) was performed more often for suspected common duct lithiasis migration (CBDL) in patients with CDL than for those without (9/21 [42.8%] vs 26/122 [21.3%]; P0.05). CBDL was present in 12 of 143 patients (8.3%). This was treated by preoperative endoscopic sphincterotomy in 10 cases, and twice by trans-cystic stone extraction during the laparoscopic intervention. CBDL occurred more frequently in association with CDL (5/21 [23.8%] vs 7/122 [5.7%]; P0.01). In addition, CDL was still present at cholecystectomy in the four patients who underwent preoperative endoscopic sphincterotomy.Cystic duct lithiasis 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.

Background Cholangitis after Roux-en-Y hepaticojejunostomy is usually caused by anastomotic stricture. A small number of cases present without evidence of obstruction and are ascribed to reflux of gastr o-intestinal content into the biliary tree above the anastomosis (sump syndrome). Despite prophylactic rotating antibiotic therapy, the cholangitic episode may be severe and life-threatening. Methods From 2001 to 2006, six patients who had undergone an end-to-side hepaticojejunostomy presented to our institution with recurrent episodes of biliary sepsis. Anastomotic stricture was excluded by liver MRI/MRCP and percutaneous transhepatic cholangiogram (PTC). Barium meal showed reflux of contrast into the biliary tree in all patients. Three patients had a short jejunal Roux limb (less than 50 cm) on pre-operative imaging. Results Five patients underwent surgery and two of them had two operations. One patient had a Tsuchida antirefux valve and subsequently underwent lengthening of the Roux loop. Three patients had lengthening of the Roux loop; one underwent re-do hepaticojejunostomy and one had concomitant revision of the hepaticojejunostomy and lengthening of the Roux loop. The latter underwent further lengthening of the Roux loop. Three patients are cholangitis-free 6, 36 and 60 months after surgery; two still experience mild episodes of cholangitis. Conclusions An adequate length of the Roux loop is important to prevent reflux. However, Roux loop lengthening to 70 cm or more does not always resolve the problem and cholangitis, although generally less frequent and severe, may recur despite appropriate reconstructive or antirefux surgery. In these cases, life-long rotating antibiotics is the only available measure.

Background: 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. Objectives: To review the biliary causes of postcholecystectomy syndrome and present a suggested diagnostic workup. Discussion: 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. Conclusion: 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.

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.

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. (Gastrointest Endosc 2002;55:163-6.)

The term postcholecystectomy syndrome (PCS) comprises a heterogeneous group of symptoms and findings in patients who have previously undergone cholecystectomy. Although rare, these patients may present with abdominal pain, jaundice or dyspeptic symptoms. Many of these complaints can be attributed to complications including bile duct injury, biliary leak, biliary fistula and retained bile duct stones. Late sequelae include recurrent bile duct stones and bile duct strictures. With the number of cholecystectomies being performed increasing in the laparoscopic era the number of patients presenting with PCS is also likely to increase. We briefly explore the syndrome and its main aetiological theories.

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.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.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%, p0.01). 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%, p0.05). 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.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.

Subtotal cholecystectomy is a well-established procedure for complicated acute cholecystitis. Short-term safety is good and few complications have been described during follow-up. However, residual gallbladder mucosa can produce new calculi, which can provoke the same symptoms and complications as those in non-operated patients and which require a high index of suspicion. Surgical treatment can be indicated. We report the case of a man who underwent subtotal cholecystectomy for complicated cholecystitis. Postoperative follow-up did not reveal residual cholelithiasis. The patient developed obstructive jaundice 8 years later. Initial studies (computed tomography and ultrasonography) showed no complications. Endoscopic retrograde cholangiopancreatography revealed residual gallbladder with recurrent cholelithiasis. Conservative management was initiated but gallbladder stump cholecystectomy was required for acute cholecystitis.

Pathophysiology of the sphincter of Oddi--or sphincter of Oddi dysfunction--manifests as either a biliary-type pain syndrome or recurrent pancreatitis. Imaging studies are unreliable, and direct endoscopic manometry is used to diagnose this entity. Milwaukee biliary classification, in addition to manometry, helps guide therapy. Endoscopic sphincterotomy in selected patients achieves permanent relief of symptoms. Endoscopic therapy for recurrent pancreatitis is still experimental.

A 52-year-old man presented to the emergency department with a one-day history of epigastric pain. The patient reported a remote history of a “difficult” laparoscopic cholecystectomy that was converted to an open cholecystectomy in 1994. Further operative details were unavailable. Multiple radiologic studies were obtained, all demonstrating a saccular cystic structure in the gallbladder fossa containing calculi. A completion open cholecystectomy, or “recholecystectomy,” revealed a remnant gallbladder with cholecystitis and cholelithiasis. Multimodality imaging findings are reviewed.

We examined 29 patients without stone disease or pancreatic ductal ectasia who underwent transduodenal sphincteroplasty and transampullary septotomy for symptoms of biliary colic or pancreatitis. The combination of biliary symptoms and a fibrotic ampulla of Vater portends a favorable surgical outcome in virtually all such patients. Patients with pancreatitis did worse overall, perhaps due to the existence of unappreciated subclinical parenchymal disease not related to sphincter dysfunction. Although endoscopic retrograde cholangiography was sensitive in demonstrating abnormalities of the pancreaticobiliary system, its specificity as a predictor of good results was poor. It seems prudent to temper one's enthusiasm for sphincteroplasty in the patient with pancreatitis, whereas patients with biliary symptoms, the postcholecystectomy syndrome, or both will usually benefit significantly from this procedure.

SUMMARY Thirty to 40 per cent of patients have symptoms after cholecystectomy (postcholecystectomy syndrome (PCS)). Organic aetiology can be found in about 50 per cent. Common duct stones and papillary stenosis are the most frequent organic biliary causes. They can be prevented by appropriate peroperative tests. Re-operation should be considered only after conservative methods of treatment have failed or wherever the causative pathology cannot be otherwise treated. Oesophagitis, ulcer, pancreatitis and liver disease are the commonest organic extrabiliary causes of PCS. These complications can arise because of incomplete preoperative diagnosis. Liver and pancreatic damage may also result from previous biliary tract disease. They can be prevented by early cholecystectomy. In the remaining 50 per cent of PCS no organic disease can be found. Metabolic changes after cholecystectomy do not seem to account for PCS. The significance of functional biliary disorders is not yet clear. The irritable colon is the most frequent of the non-organic extrabiliary disorders.

Fifty-six consecutive patients returning with recurrent or persistent upper abdominal pain after cholecystectomy were studied by endoscopic retrograde cholangiopancreatography, abdominal ultrasound and morphine neostigmine test. In 44 patients, pain recurred within 6 months after cholecystectomy. Forty patients were demonstrated on endoscopic retrograde cholangiopancreatography to have moderate to marked ampullary stenosis, which occurred as an isolated abnormality in 32 patients and in association with pancreatitis in 8. Thirteen patients were found to have pancreatitis, and 6 had retained common duct stones. In five patients no definite abnormality was demonstrated. The morphine neostigmine test was positive in 16 of 17 patients with isolated ampullary stenosis and in only 1 of 8 with pancreatitis. This test may be helpful in patients who are to undergo cholecystectomy. In those with positive results, endoscopic retrograde cholangiopancreatography would help assess the size of the ampullary sphincter so that sphincteroplasty could be done at the time of cholecystectomy in appropriate patients.

Pancreas divisum is a congenital variant of pancreatic duct drainage in which the dorsal duct dominates, most likely due to the failure of the two independent pancreatic ductal systems to fuse embryologically. Although 5 to 10 percent of the population have this congenital variation, few demonstrate symptoms related to their pancreaticobiliary ductal systems. However, patients may present with symptoms referable to this system, and the diagnosis is difficult. In this series, endoscopic retrograde cholangiopancreatography with cannulation and radiographic injection of the dorsal duct demonstrated this abnormality in 30 of 32 patients, and results of morphine-prostigmine testing were positive for symptoms, chemical enzyme elevation, or both in three fourths of the patients tested, but other maneuvers were not as helpful. The surgical approach has been to perform a sphincteroplasty of both the main and accessory ampullas and to excise the gallbladder when it is present. Pathologic study of the gallbladders showed nearly all of them to have been diseased, whereas histologic study of the ampullas was not as conclusive. In general, this condition should be suspected as part of the postcholecystectomy syndrome or in patients who present with idiopathic pancreatitis and whose conditions cannot be identified by all other diagnostic methods. Preoperative screening may be carried out with noninvasive techniques such as the morphine-prostigmine test, or by use of the secretin-stimulated ultrasonographic visualization of the ductal system. The primary tool for making the diagnosis is endoscopic retrograde cholangiopancreatography. The goal of surgical treatment should be the opening of the main and accessory ducts, since this offers the best chance for long-term relief of the patient's symptoms.

In order to assess the role of 99mTc-iminodiacetic acid (IDA) cholescintigraphy in evaluating postoperative patients, a total of 213 studies were performed in 189 patients over a 3-year time period. Of these, 130 studies were obtained in 125 cases with signs and/or symptoms suggesting postcholecystectomy syndrome. A normal sized duct that emptied within an hour ruled out significant pathology with a high degree of accuracy (97%). A less reliable finding of normalcy was the combination of ductal dilatation with functional patency in that three of 20 patients (15%) who exhibited this pattern were proven to have nonobstructing calculi in their common bile duct. AZ spectrum of abnormal findings was encountered. Ductal dilatation was a most significant indicator of partial or intermittent ductal obstruction when it was associated with altered time-activity dynamics in the ducts and secondarily, delayed biliary-to-bowel transit time of the radiotracer. Patterns indicating complete common duct obstruction, cystic duct remnants, and bile leaks also proved to be very sensitive. Seventy-three studies in 56 patients very accurately evaluated the integrity of biliary-enteric bypass anastomosis. Complete and partial obstructive patterns were similar in appearance to those encountered in postcholecystectomy syndrome. Several leaks were also detected in this patient population. Ten studies were performed in eight patients who underwent Billroth II gastroenterostomies primarily to see if afferent loop obstruction was present. Three of these patients did demonstrate dilated A-loops with stasis, thereby making a positive diagnosis possible.

"re-formed gall bladder" in his description of the condition. The term "re­ formed gall bladder" should be applied to those cases in which incomplete or subtotal cholecystectomy had been performed. Since the symptomatology may be caused by other pathophysiologic changes, a more descriptive term for this condition would be postcholecystectomy cystic duct syndrome. This syndrome may be caused by a number of conditions: disease originating remotely from the biliary tract; residual hepatitis, cholangitis and/or pancreatic disease; biliary dyskinesia or dyssynergia; stones in the hepatic and/or common bile ducts; and cystic duct pathology produced by inflammation, adhesions and stones. Disappointing surgical results with recurrence of symptoms are observed in from 20 to 40 per cent of postcholecystectomy cases. The vast majority of these occur, following surgery of the non calculous gall bladder. In a study of cholecy­ stectomized patients, Meyers and his colleagues 24 found that 83 per cent of calculous cholecystitis cases were benefited, while only 41 per cent were symptom­ atically relieved in the noncalculous group. Causes Biliary dyskinesia. Deserving of comment is the question of functional disorders of the sphincter of Oddi. The frequency of disturbance of the sphincter of Oddi mechanism as a contributing factor in the production of symptoms has been a controversial issue. Some authorities believe that biliary dyskinesia accounts for the majority of cases of recurrence of symptoms, while others believe that it plays but a small part. Womack and Crider40 have questioned whether the part played by the sphincter of Oddi and the mechanism of reciprocal innervation is a dominant one. Lehmann 18 has shown that dyskinesia of the sphincter of Oddi does not playa significant role in causing pain. According to Upham,39 the role of spasm of the sphincter of Oddi is no longer felt to be the leading cause of postcholecystectomy syndrome. Mallet-Guy and Rose 20 found in manometric studies that spasm occurred in 20 per cent of cholecystectomized

Summary Intravenous cholangiograms using Biligrafin were performed on 23 patients suffering from the ‘post-cholecystectomy syndrome’ and the results compared with those in 39 post-cholecystectomy patients without symptoms. Abnormalities in the patients with symptoms that were considered of definite significance were stones in the common bile-duct (4 instances in the 23 cases) and stone in the cystic duct stump (1 instance out of 23). Findings considered of possible significance were a persistent cystic duct stump (3 instances) and kinking and distortion of the main duct (1 instance). Because it was such a frequent occurrence in symptom-free patients, dilatation of the bile-ducts was considered to be of no significance in a patient with symptoms after cholecystectomy; similarly, no significance could be attached to constriction of the ducts or to biliary stasis. Physiological dilatation of the ducts after cholecystectomy is shown not to be the rule in man. Evidence is presented for the view that dilatation of the ducts is in fact a permanent result of back-pressure, owing to obstruction of the common duct at some stage by stone.

Sphincter of Oddi pressure (SOP) was measured in 50 consecutive patients referred for evaluation of acute pancreatitis (15 patients), recurrent pancreatitis (21 patients), and postcholecystectomy syndrome (14 patients). The mean SOP (±standard error) in the patients with acute pancreatitis (40 ± 4 mm Hg) and recurrent pancreatitis (50 ± 6 mmHg) was significantly greater (P .05) than that of normal control subjects (31 ± 2 mm Hg). The clinical efficacy of this new procedure remains to be determined.