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

Discussion

Compared with the general population, our study population appeared to exhibit an increased risk for gallstone disease: 13% had preoperative and 9% postoperative cholecystectomy. The incidence of gallstones or sludge preoperatively was 22%; other studies show an incidence in the general population of 9%.[8] Our data showed a high incidence of gallstone formation after transplant (55%). These data may be confounded since these studies were partially obtained because of symptoms and not routinely. However, several other groups have also concluded that this is a high-risk population.[2,7] In mid-1998 we began using tacrolimus in 90% of our patients. Scientifically this may reduce the risk of gallstones; however, we did not have enough patients in this group to make any conclusions.[9]

The risk for gallstone disease was very high for patients who developed biliary tract disease during hospitalization for transplant. Indeed, the risk of mortality (omitting the patient with the normal cholecystectomy) was 2.6% in this group. Several studies have shown that laparoscopic cholecystectomy is safe (with aggressive monitoring) in high-risk cardiac patients.[2,3,4] It is not well documented whether cholecystectomy is safer in patients on the transplant list or posttransplant. In fact, Menegaux et al. found no complications when patients did not undergo cholecystectomy pretransplant even when they were symptomatic.[5] However, the number of cases in their study was small. It is difficult for us to perform cholecystectomy pretransplant because many patients are urgently brought to transplant with no time for cholecystectomy. The majority of patients undergoing cardiac transplantation at our center do so in "urgent" status and are typically refractory to oral medical therapy. Such patients often await transplant in an ICU area bound to intravenous inotropic therapy or mechanical cardiac support, and it is usually not feasible to perform elective cholecystectomy before transplant because of the excessive perioperative risk. Left ventricular assist device (LVAD) implant or explant is an opportunity for cholecystectomy, but it has not been our practice to do so. Most of our patients have been too unstable at LVAD implantation to add this procedure on. Theoretically, cholecystectomy could cause bacteremia, which might affect the LVAD implant or transplanted heart, although we believe this has not been seen in practice. Further, we currently place LVADs preperitoneally, and cholecystectomy would therefore involve opening another body cavity.

The results of the present study agree with those of our prior study[7] and others[2] that laparoscopic cholecystectomy is safe when cardiac transplant patients do not have acute cholecystitis. Recently, we have increased the frequency of performing laparoscopic cholecystectomy on an outpatient basis and have rarely seen complications from perioperative hemodynamic changes.

Compared with patients with biliary colic, outcomes for patients with acute cholecystitis after transplant were much worse: increased operative time, length of hospital stay, complications, and death. Postoperative courses for laparoscopic or open surgery were similar, as Gupta et al. also found.[2] However, Lord et al. found only 13.8% morbidity and no mortality in their series, which combined patients with biliary colic and those with acute cholecystitis.[10] They concluded that there was no increased risk of waiting for symptoms to occur before cholecystectomy was performed. Our data suggest that their morbidity would be decreased if they were operating on fewer patients with acute cholecystitis.

In patients with biliary colic, our data compare well with those of the general population. However, in our patients with acute cholecystitis, the results are much worse. Our major morbidity was 47% compared with 4.4% and mortality was 0.5% compared with 0% for acute cholecystitis in the general population.[11]

Severe pancreatitis carried a high risk of death. When mild, we treated it the same as in nontransplant patients, with good results. Cholangiograms should be performed to indicate the necessity of treating retained stones and to prevent them from becoming symptomatic.

Because of the high morbidity and mortality of gallstones in cardiac transplant patients, we now routinely perform annual ultrasounds to look for gallstones. When they are found, elective cholecystectomy is performed as long as allograft function is good.

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