The Causes Of Repetitive Symptoms After Cholecystectomy In Patients With Benign Gallbladder Diseases

Background:The incidence rate of benign gallbladder disease is high and increasing year by year.Whether in developed or developing countries,gallbladder disease is an important public health problem affecting human life and health.After cholecystectomy,some patients will experience symptoms such as abdominal pain、bloating and diarrhea,which are often diagnosed as postcholecystectomy syndrome(PCS).Patients often go to hepatobiliary surgery and gastroenterology repeatedly after the operation,and the effects always vary among patients,resulting in waste of medical resources and even harm the relationship between doctors and patients.In fact,the diagnosis of PCS is relatively general and lacks accuracy,which cannot explain the real reason for symptoms reappearing after the operation.The clinical manifestations of benign diseases of the gallbladder,such as(right)epigastric pain,epigastric distension,and right epigastric/xiphoid tenderness,are similar to those of other diseases of the upper digestive tract,with overlapping symptoms and are prone to misdiagnosis and missed diagnosis.With the proposal of the"bio-psycho-social medical model",the relationship between digestive system diseases and psychological factors has received extensive attention from scholars at home and abroad.More and more studies have shown that digestive system diseases such as functional gastrointestinal diseases(FGIDs),gastroesophageal reflux disease,etc.are closely related to psychosocial factors,and a significant proportion of patients with anxiety and depression complain of various physical discomfort such as abdominal pain,abdominal distension,and other symptoms similar to gallbladder diseases,and first go to the gastroenterology department for treatment.However,many doctors lack the understanding of psychosomatic diseases and do not pay attention to psychological factors such as depression and anxiety associated with digestive diseases,which often leads to unnecessary cholecystectomy.At present,for patients diagnosed with benign gallbladder diseases who did not meet the absolute indications for surgery,there are few relevant studies at home and abroad on the status quo of repetitive symptoms after cholecystectomy,and there is a lack of systematic and clear analysis of the causes.Objective:To analyze the status quo and causes of repetitive symptoms after cholecystectomy in patients with benign gallbladder diseases that did not meet the absolute surgical indications,and proposed corresponding countermeasures aiming to guide clinicians in the correct understanding of benign gallbladder diseases,accurate analysis of possible causes of preoperative symptoms and careful grasp of indications for cholecystectomy.Methods:In this study,in strict accordance with the inclusion criteria and exclusion criteria,the clinical data of91 patients with benign gallbladder disease who did not meet the absolute indications for surgery in the Department of Gastroenterology and Hepatobiliary Surgery of our hospital from 2017 to 2022 were collected,and the symptoms,etiology,surgical effect,depression/anxiety state and postoperative treatment were retrospectively and prospective analyzed.Results:A total of 91 patients were enrolled in this study,all of whom were benign gallbladder diseases that did not meet the absolute indications for surgery,84.6%of cases(77/91)suffered from gallbladder stones(χ~2=225.945,P<0.001).There were 5 kinds of symptoms that did not meet the absolute indications for surgery,the proportion of chronic right upper abdominal pain without acute attack was the most common symptom,accounting for 42.9%(39/91)(χ~2=52.665,P<0.001).The patients with persistent preoperative symptoms were the most common,accounting for 47.2%(43/91)(χ~2=12.000,P=0.002).There were 49 cases of missed diagnosis or misdiagnosed before cholecystectomy,the rate of missed diagnosis was 20.9%(19/91),and the rate of misdiagnosis was 32.9%(30/91).Among the 49 patients who were missed or misdiagnosed before surgery,19 cases underwent cholecystectomy in our hospital,with a total missed/misdiagnosed rate of 2.6‰(19/7254)(Note:7254 patients underwent cholecystectomy in our hospital in the six years of this study).The most common missed/misdiagnosed disease was functional gastrointestinal diseases(FGIDs),accounting for 71.4%(35/49)(χ~2=102.653,P<0.001),while 82.9%of cases with FGIDs(29/35)suffered from depression and/or anxiety.Some patients were treated with antidepressant/anxiety drugs,the depression and anxiety were significantly relieved,and the effective rates were 75.0%(12/16)and 70.8%(17/24),respectively.There were 14 patients missed/misdiagnosed organic diseases before operation,the most preoperative symptoms were chronic right upper abdominal pain without an acute attack 42.9%(6/14),and 78.6%(11/14)of the patients had persistent preoperative symptoms after operation.Forty-three cases(47.3%)were directly diagnosed with PCS by a competent physician without considering the possibility of missed diagnosis or misdiagnosis.These patients were treated with alternative gallbladder function therapy,including bile excretion drugs and digestive enzyme preparations,which the total effective rate was 41.9%(18/43),and the therapeutic effect was poor.25 PCS patients with ineffective treatment by gallbladder function replacement therapy were treated according to FGIDs(with or without depression/anxiety),reflux esophagitis,or peptic ulcer,and 20 patients showed significant improvement in symptoms.The total effective rate of remedial diagnosis and treatment reached 80.0%(20/25).Conclusions:(1)Benign gallbladder diseases are easily confused with other upper gastrointestinal tract diseases,especially FGIDs with depression/anxiety.(2)PCS is only a symptom diagnosis,not a causal diagnosis,which cannot explain the real reason for symptoms reappearing after the operation.It should be diagnosed with caution.(3)Preoperative missed diagnosis and misdiagnosis,surgical indications that are not strictly limited,and lack of understanding of psychological factors are the possible causes of repetitive symptoms after cholecystectomy for benign gallbladder diseases.