Gallstone Disease in Heart Transplant Recipients

William S. Richardson, MD, Walter J. Surowiec, MD, Kristine M. Carter, MD, Todd P. Howell, MD, Mandeep R. Mehra, MD, John C. Bowen, MD

Disclosures

Annals of Surgery. 2003;237(2) 

In This Article

Results

Due to our observation of excess morbidity associated with cholelithiasis, pretransplant surveillance for gallbladder disease has been practiced universally since 1996. However, posttransplant surveillance is not routinely practiced, and abdominal ultrasonography was performed posttransplant in the series only at the discretion of the transplant physician, largely due to the development of symptoms.

Sixty-eight patients (13%) had gallbladder surgery before transplant. One hundred twenty-three patients (23.7%) had no ultrasound and no history of cholecystectomy. An initial ultrasound showed gallstones or sludge in 114 (22%). No gallstones were noted on initial ultrasound in the remaining 204 (39%).

Fifty-three (10%) had multiple postoperative ultrasounds. Of these, 29 (6%) developed gallstones. After transplant 55% developed gallstones. No follow-up ultrasounds were performed for 456 (90%).

After transplant, 47 patients (9%) (35 men, 12 women) underwent cholecystectomy. Their average age was 54 ± 12 years (range 25-74). Thirty-seven were white, eight African American, and two Hispanic. Eleven patients had elevated serum cholesterol levels.

Five cholecystectomies were performed during the immediate transplant hospitalization. Four deaths occurred in this group. One patient had open cholecystectomy for cholecystitis 18 days after transplant and died 6 days later of transplant rejection. Another had cholecystitis and choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) 28 days posttransplant followed by open cholecystectomy on postoperative day 32 and died of sepsis and disseminated intravascular coagulation. At the time of cholecystectomy his EF was less than 25%. One had biliary colic and ileocecitis with gastrointestinal bleeding and underwent open cholecystectomy and ileocecectomy 36 days postoperatively. Pathology of the gallbladder was normal. He underwent reoperation for sepsis and eventually died of sepsis and renal failure. His EF at the time of cholecystectomy was 50% to 55%. One patient had open cholecystectomy for cholecystitis 28 days postoperatively and died of ongoing sepsis and multisystem organ failure. The one survivor had pancreatitis and cholecystitis and underwent open common duct exploration and cholecystectomy 12 days postoperatively. He was re-explored 3 days later for bleeding. In this group two patients had cholelithiasis, one had choledocholithiasis (presumably originally from gallstones) but not cholelithiasis, one had gallbladder sludge, and one had no gallstones.

Table 1 summarizes morbidity and mortality for the patients who had cholecystectomy after discharge (40 at our institution and 2 at outside facilities). Sixteen patients were operated on for biliary colic. All had EFs greater than 45% (data missing for one patient). Mean operating time was 54 ± 12 minutes. Length of hospital stay was outpatient for one patient, 1 day for 12 patients, and one patient each for 2 days (because of acute cholecystitis found at operation), 3 days (to control arrhythmia), and 6 days (because of ileus). One patient who stayed 1 day was readmitted for treatment of depression. Pathologic specimens showed gallstones in 13, cholesterolosis in 2, and only chronic cholecystitis in 1.

Nineteen patients were operated on for acute cholecystitis. In all but two patients the EF was above 40%. Mean operating time for the four open procedures was 94 ± 36 minutes. Mean length of hospital stay was 6 days (range 4-13), except for the patient who died on postoperative day 8 of acute respiratory distress syndrome, cytomegalovirus, and amiodarone toxicity. The patient who stayed 13 days had sepsis and acute renal failure. Of the 15 patients operated on laparoscopically, 2 required open cholecystectomy. Mean length of operative procedure was 95 ± 38 minutes, including the converted cases (data missing for two patients), and mean length of hospital stay was 5 ± 5 days, except for one patient who stayed 4 months (because of respiratory failure and renal failure). Hospital stay was increased for intravenous antibiotic to treat cholecystitis. In addition, two patients had postoperative renal failure, one had rejection, and three were readmitted (one for rejection, one for rehydration, and one for pneumonia and renal failure). None of these patients died. Results of pathologic examination revealed 16 patients with cholecystitis (2 with acalculous cholecystitis) and 1 with cholelithiasis; two reports were missing.

Of five patients operated on for biliary pancreatitis, three had acute cholecystitis and two had a history of biliary colic. All had a normal EF. Two had preoperative ERCP. One had ERCP 6 years postoperatively. Only one cholecystectomy was performed by the open approach (155 minutes). Mean length of the four laparoscopic procedures was 74 ± 33 minutes. Mean length of hospital stay was 2 days (range 1-4), with the exception of one death 4 days postoperatively of unknown causes.

One patient was operated on laparoscopically for chronic cholecystitis, stayed 1 hospital day (length of procedure unknown), and had no complications. One patient operated on laparoscopically for unknown indications had an EF of 60%, was readmitted postoperatively with pancreatitis and disseminated intravascular coagulation, and died 27 days postoperatively.

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