Are postcholecystectomy syndromes predictable and preventable?

Authors

Abstract

AimPostcholecystectomy syndrome (PCS) is a heterogeneous clinical condition characterized by persistent or newly developed abdominal symptoms after cholecystectomy, which may complicate postoperative management. The aim of this study was to evaluate the effect of a preoperative history of acute attacks on the development, type, and postoperative intervention requirements of PCS, and to investigate the predictability and preventability of PCS.
MethodsThis retrospective study included 359 patients who underwent cholecystectomy for gallbladder disease in the general surgery clinic of a tertiary care training and research hospital. Patients were categorized according to the presence of a history of acute attacks and compared in terms of the incidence of postcholecystectomy syndrome, symptom type, and the need for postoperative diagnostic and interventional procedures.
ResultsPostcholecystectomy syndrome (PCS) was observed in 172 of 359 patients (47.9%). PCS was significantly more frequent in patients without a history of acute attacks (56.1% vs. 39.7%, p=0.002). In multivariable analysis, a history of acute attacks was independently protective against PCS, whereas postoperative complications were significantly associated with PCS.
ConclusionPostcholecystectomy syndromes exhibit distinct clinical characteristics depending on the presence of a preoperative history of acute attacks. Careful evaluation of the preoperative clinical history, particularly the presence of acute attacks, may help predict the likelihood and type of postcholecystectomy syndrome and identify patients at higher risk of persistent postoperative symptoms.

Keywords

Introduction

Cholecystectomy is one of the most commonly performed surgical procedures for the treatment of gallstone disease. Nevertheless, in some patients, symptoms such as abdominal pain, dyspeptic complaints, or jaundice may persist or newly develop in the postoperative period.¹ This clinical condition is defined as postcholecystectomy syndrome (PCS).²
Postcholecystectomy syndrome is a heterogeneous clinical entity that may arise from both biliary and non-biliary causes.³ In addition to biliary pathologies such as choledocholithiasis, bile leakage, and biliary strictures, functional gastrointestinal disorders and other extra-biliary conditions are also included in the etiology of PCS.⁴ This broad etiological spectrum complicates the diagnosis and management of PCS and adversely affects patient satisfaction.
Preoperative factors that may predict the development of postcholecystectomy syndromes have not been clearly established in the literature.⁵ In particular, the impact of a preoperative history of acute attacks on the type of postoperative symptoms and subsequent treatment requirements remains controversial.⁶ The aim of this study was to evaluate the role of a history of acute attacks in the development and characteristics of postcholecystectomy syndromes.

Materials and Methods

This retrospective study was conducted in the general surgery clinic of a tertiary care training and research hospital and included patients who underwent cholecystectomy for benign gallbladder disease. This study was reported in accordance with the STROBE statement. Patients who underwent cholecystectomy between January 1, 2020, and December 31, 2020, were included in the study. Patients were divided into two groups according to the presence or absence of a preoperative history of acute attacks. Postoperative symptoms were evaluated during routine outpatient follow-up visits and through review of hospital records. PCS was defined as the persistence or new onset of abdominal symptoms during the postoperative follow-up period. The minimum follow-up period for symptom assessment was three months after surgery. PCS symptoms were classified as biliary or non-biliary. Biliary PCS included conditions such as retained bile duct stones, bile leakage, biliary strictures, or other biliary tract pathology confirmed by imaging or endoscopic evaluation. Non-biliary PCS included extra-biliary causes such as gastritis, gastroesophageal reflux disease, or functional gastrointestinal disorders. These diagnoses were established based on clinical evaluation and, when indicated, diagnostic procedures such as upper gastrointestinal endoscopy and imaging studies. Patient data were obtained from the hospital electronic medical record system and patient files. Demographic characteristics, surgical indications, preoperative history of acute attacks, postoperative complications, presence of postcholecystectomy syndrome, symptom type, and diagnostic and interventional procedures performed in the postoperative period were recorded.
Ethical ApprovalThe study was approved by the Clinical Research Ethics Committee of University of Health Sciences Dışkapı Yıldırım Beyazıt Training and Research Hospital (Date: 03.05.2021, Decision No: 110/04).
Statistical AnalysisStatistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as numbers and percentages for categorical variables and as mean ± standard deviation or median (minimum–maximum) for continuous variables. The normality of data distribution was assessed using histograms, probability plots, and the Kolmogorov–Smirnov test. Pearson’s chi-square test was used to compare categorical variables between groups, and the Mann–Whitney U test was used for intergroup comparisons of continuous variables. Variables considered clinically relevant or showing a potential association in univariate analyses were included in the multivariable logistic regression model to evaluate factors independently associated with PCS. A p value <0.05 was considered statistically significant.
Reporting GuidelinesThis study was reported in accordance with the STROBE guideline.

Results

A total of 359 patients were included in the study. Of the patients, 68% were female, and the mean age was 49.5±13.9 years. At least one comorbidity was present in 55.2% of the patients, and nearly half of the cohort (49.9%) had a preoperative history of acute attacks. Evaluation of ASA scores showed that the majority of patients were classified as ASA I–II.
When patients were compared according to the presence of a history of acute attacks, no statistically significant difference was observed between the groups in terms of postoperative complication rates (p=0.210). In contrast, the development of postcholecystectomy syndrome (PCS) was significantly more frequent in patients without a history of acute attacks compared with those with such a history (56.1% vs. 39.7%, p=0.002). Analysis of PCS symptom distribution revealed that non-specific abdominal pain and gastritis/reflux-like symptoms were predominant in patients without a history of acute attacks, whereas biliary-related causes such as choledocholithiasis and bile leakage were more frequently observed in patients with a history of acute attacks (p=0.001). The rate of any postoperative diagnostic or interventional procedure was higher in patients without a history of acute attacks (55/180; 30.6% vs. 27/179; 15.1%; p<0.001). Among patients who underwent a postoperative intervention, the rate of ERCP was significantly higher in those with a history of acute attacks (8/27; 29.6% vs. 2/55; 3.6%; p=0.001).
In the multivariable logistic regression analysis performed to evaluate factors associated with the development of PCS, the presence of a history of acute attacks was identified as an independent protective factor against PCS (OR: 0.526; 95% CI: 0.342–0.808; p=0.003). Increasing age was independently associated with the development of PCS (OR: 1.018; 95% CI: 1.002–1.035; p=0.027), while the presence of postoperative complications was identified as a significant risk factor for PCS (OR: 6.493; 95% CI: 1.290–32.686; p=0.023). Preoperative endoscopy, sex, and ASA score were not independently associated with the development of PCS.
The detailed data are provided in Supplementary Tables 1, 2 and 3.

Discussion

Although cholecystectomy is the standard treatment for symptomatic gallstone disease, persistent or newly developed symptoms may occur in some patients during the postoperative period. This condition is defined in the literature as postcholecystectomy syndrome (PCS), and its reported incidence varies widely.^2,4 PCS may arise from both biliary and non-biliary causes, and inadequate preoperative evaluation of symptoms may lead to postoperative patient dissatisfaction.⁶ In this study, the frequency and clinical characteristics of PCS were evaluated in patients undergoing cholecystectomy, with particular emphasis on the impact of a preoperative history of acute attacks on the development of PCS.
Evaluation of the demographic and clinical characteristics of the study population revealed a predominance of female patients and a middle-aged cohort, consistent with the literature.^7,8 More than half of the patients had at least one comorbidity, with hypertension and diabetes mellitus being the most common. The majority of patients were classified as ASA I–II, indicating a generally low-to-moderate surgical risk profile. These findings suggest that the development of PCS cannot be explained solely by surgical risk or comorbidity burden.
When patients were evaluated according to the presence of a history of acute attacks, PCS was found to be significantly more frequent in patients without such a history. This finding is consistent with previous studies^6,9 emphasizing that PCS may predominantly arise from non-biliary causes. In patients without a history of acute attacks, the higher prevalence of non-specific abdominal pain and gastritis- or reflux-like symptoms suggests that preoperative complaints may be related to extra-biliary causes. This observation highlights the importance of careful preoperative symptom assessment and appropriate management of patient expectations prior to cholecystectomy.
In contrast, patients with a history of acute attacks more frequently exhibited biliary-related causes of PCS and a higher need for interventional procedures. The increased prevalence of pathologies such as choledocholithiasis and bile leakage, along with the significantly greater requirement for ERCP in this group, supports the association between acute attack history and biliary pathology.¹⁰ These findings suggest that PCS in patients with a history of acute attacks is more often attributable to identifiable and potentially treatable biliary causes, whereas PCS in patients without such a history is more likely related to non-biliary and functional etiologies. Therefore, careful evaluation of the preoperative clinical history may play an important role in predicting PCS and optimizing patient selection.¹¹
In the present study, the finding that a history of acute attacks was independently protective against the development of PCS may be explained by the fact that surgical indications in these patients are typically based on a clinical context dominated by biliary symptoms, which are directly alleviated by cholecystectomy. In contrast, in patients without a history of acute attacks, some preoperative symptoms may be attributable to extra-biliary causes, resulting in persistence of symptoms in the postoperative period and subsequent classification as PCS. Recent studies¹² have emphasized the heterogeneous etiology of PCS and the significant contribution of non-biliary causes, such as gastritis, gastroesophageal reflux disease, and functional bowel disorders, within the PCS spectrum. This may clinically explain the higher frequency of non-specific symptoms observed in patients without a history of acute attacks in the present study. On the other hand, the independent association between postoperative complications and PCS suggests that PCS may also be shaped by concrete postoperative events, such as bile leakage, biliary injury or stricture formation, and residual stones. Current guidelines¹³ indicate that postoperative biliary complications may prolong clinical symptoms and increase symptom burden by triggering diagnostic and therapeutic interventions, including ERCP.

Limitations

The main limitations of this study include its retrospective design, single-center data, and the difficulty in objectively classifying certain non-biliary symptoms due to the heterogeneous nature of postcholecystectomy syndrome.

Conclusion

In conclusion, the preoperative clinical history -particularly the presence of acute attacks- appears to be an important determinant in predicting postcholecystectomy syndrome, and careful patient selection and thorough preoperative symptom evaluation may help reduce postoperative symptom burden.

Declarations

Abbreviations

ASA: American society of anesthesiologists
CI: Confidence interval
ERCP: Endoscopic retrograde cholangiopancreatography
OR: Odds ratio
PCS: Postcholecystectomy syndrome

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About This Article

Received:

February 8, 2026

Published Online:

June 18, 2026