Cholelithiasis and aortic reconstruction: The problem of simultaneous surgical therapy

Transcription

1 Cholelithiasis and aortic reconstruction: The problem of simultaneous surgical therapy Conclusions from a personal series Richard E. Fry, M.D., and William J. Fry, M.D., Dallas, Tex. From 1976 to 1983, 682 patients have undergone aortic reconstruction at Parkland Memorial Hospital and the Veterans Administration Hospital in Dallas, Texas. Thirtyfive patients (5.1%) had a biliary tract operation performed before, during, or after their aortic procedure. Fourteen percent of patients had bacteria in the bile and 11.4% needed common bile duct exploration. Twelve patients had their aortic reconstruction first. Biliary pancreatitis developed postoperatively in one patient. Two patients who had infected prostheses removed had acalculous cholecystitis after operation and one had jaundice and fever 3 years after operation, but no biliary disease was found. Twenty-one patients had the biliary procedure first. Four patients were operated on for suspected aneurysm rupture an average of 18 months after operation. There was one true rupture; this patient had no gallstones. One patient had acute aortic thrombosis 10 days after emergency operation for acute cholecystitis. Only two patients underwent combined operative procedures; both were patients with acute aortic problems in whom chronic and snbacute biliary disease was found. Eight operative deaths occurred, all in the patients undergoing aortic procedures. There were no ruptured aneurysms or acute biliary problems needing emergency operation in any patient with cholelithiasis. On the basis of our experience, we believe that concomitant cholecystectomy and aortic reconstructions rarely need to be performed and then only in those patients in whom the risk of not treating both biliary and aortic conditions is greater than the operative risks. In these circumstances, cholecystostomy should be considered to decrease operative time and the risk of graft contamination. (J V^sc SvgG 1986; 4: ) Performance of concomitant operations has always been controversial, which is especially true when one of the operations is an aortic reconstruction. Increased operating time, with the chance of an increased mortality rate and the risk of graft contamination, make combined procedures less appealing in this setting. Recent reports have described the apparent safety and desirability of combining cholecystectomy with aortic reconstruction. To examine this premise, we completed a retrospective analysis of our experience with patients who had both biliary and aortic operations. From the Department of Surgery, University of Texas Health Science Center. Presented at the Tenth Annual Meeting of the Southern Association for Vascular Surgery, Cerromar Beach, Puerto Rico, Jan. 30-Feb. 1, Reprint requests: Richard E. Fry, M.D., University of Texas Health Science Center, 5323 Harry Hines Blvd., Dallas, TX PATIENTS AND METHODS From 1976 to i)83, 682 patients underwent abdominal aortic reconstruction at Parkland Memorial Hospital and the Veterans Administration Hospital in Dallas, Texas (Table I). Two hundred thirty-nine patients (group I) had abdominal aortic aneurysms (AAAs) and 443 patients (group II) had aortoiliac or renal artery occlusive disease (AIOD/RAOD). Thirty-five patients (5.1%) had a biliary procedure performed before, during, or after an aortic operation. Twenty-five of the 35 patients (71%) had symptomatic cholelithiasis. Group I consisted of 18 patients and group II had 17 patients. The average age was 60 years (range, 43 to 79 years). There were 27 men and eight women. Four patients required common bile duct exploration. Because of incomplete records the actual number of patients with bacteria in the bile was not determined, but five patients did have a record of positive biliary cultures, so the minimum incidence was 14.3%. 345

2 346 Fry and Fry Journal of VASCULAR SURGERY Table I. Patient groups Group No. of patients Cholelithimis Common duct Infected bile* AAA (7.5%) 1 (5.6%) 3 (16.7%) AIOD/RAOD 44._33 17 (3.8%) _3 (17.6%) 2 (11.8%) Total (5.1%) 4 (11.4%) 5 (14.3%) AAA = abdominal aortic aneurysm; AIOD/RAOD = aortoiliac or renal artery occlusive disease. *Minimum incidence (for details see text). Table II. Operative priority Vascular Biliary Group No. of patients first first Simultaneous AAA * AIOD/RAOD For legend see Table I. *All emergency procedures. The inpatient and outpatient records of these persons were reviewed. In each case, the decision to perform either a biliary or vascular operation as the primary procedure was made on the basis of (1) size of the AAA: those greater than or equal to 5 cm were usually operated on first; and (2) the presence of biliary symptoms: asymptomatic patients were done after the vascular procedure. In the case of a large aneurysm and biliary symptoms, then the cholecystectomy was usually completed first. The incidence of aortic and biliary complications was noted as well as morbidity and mortality rates. Length of time between operations was correlated with the need for later emergency aortic and biliary operation. RESULTS Group I: Abdominal aortic aneurysms. In group I, 13 patients had the biliary procedure performed first (Table II). It is significant that two people were operated on for suspected ruptured aneurysms only to find that they had gangrenous and perforated gallbladders. Nine patients in this group had acute or subacute cholecystitis. Four patients later underwent emergency operation for suspected aneurysm rupture, at an average of 18 months after their cholecystectomy. Only one patient had aneurysm rupture discovered at operation; this patient had a thoracoabdominal aneurysm that ruptured 8 days after his gallbladder was removed to correct "biliary apoplexy." There was no cholelithiasis; gangrene of the gallbladder was thought to be caused by arterial occlusion and resultant infarction from an embolus occurring as a result of aneurysm expansion (Table III). The remaining nine patients had elective aortic reconstruc- tion an average of only 4 months after cholecystectomy. Three patients with aneurysms had the aneurysms repaired first. Only one patient had biliary pancreatitis (8 months after operation). He did not require emergency operation and was able to undergo cholecystectomy after the pancreatitis resolved. The remaining two patients underwent elective cholecystectomy an average of 11 months after aneurysm repair. One common duct exploration was done in this group and this patient had infected bile. Two patients underwent simultaneous AAA repair and cholecystostomy. One man had an expanding aneurysm and operation revealed an inflamed gallbladder as well. The surgeons were able to palpate stones in the common bile duct. They inserted a cholecystostomy tube after the aortic repair was completed and carefully peritonealized the graft again. Interval cholecystectomy and common bile duct exploration were performed 2 months after the primary operation. Bile cultures later grew anaerobes and no wound or graft infection occurred. The second patient had a ruptured aneurysm and primary aortoenteric fistula. At operation an inflamed gallbladder with obvious gallstones was found. The surgeons thought that this patient was at high risk for postoperative cholecystitis and a cholecystostomy tube was placed after the vascular procedure. This patient died of sepsis and multisystem organ failure in the immediate postoperative period. There was no record of bile cultures. Group II: Occlusive disease. Nine patients with occlusive disease had aortic procedures completed first. Two of these operations were performed to remove infected aortic prostheses. Three patients re-

3 m m Volume 4 Number 4 October 1986 Cholelithiasis and aortic reconstruction 347 Table III. Emergency secondary operations No. of Emergency Aneurysm Acute Group patients biliary rupture ischemia AAA AAA first 3 0 Biliary first AIOD/RAOD Aorta first 9 0 Biliary first 8 -- For legend see Table I. *Rupture in patient with no gallstones (for details see text). 1 Table IV. Morbidity and mortality data for all groups Total Group patients Complications Deaths Elective* Emergency * AAA Elective 12 (67%) 3 (25%) 2 (16.7%) Emergency, 6 (33%) 4 (67%) 3 (50%) AIOD/RAOD Elective 14 (82.4%) 0 (0%) 1 (7%) Emergency 3 (17.6%) 3 (100%) 2 (67%) Total 35 (100%) 10 (28.5%) 8 (22.8%) 3/26 (11.5%) 5/9 (55.6%) *All groups. quired emergency operations for biliary problems. The two patients with infected grafts had acute acalculous cholecystitis in the immediate postoperative period and cholecystectomies were performed. Both of these patients died of complications from graft and biliary sepsis. The third patient had a fever of unknown origin and jaundice 3 years after his aortic reconstruction. He underwent cholecystostomy, but no biliary disease was found and recovery was uneventful. The remaining six patients had elective cholecystectomies an average of 18 months after aortic or renal bypass. Two of the six patients had infected bile and none required a common duct exploration. Eight patients with AIOD/RAOD underwent cholecystectomy first. Three patients in this group required common duct explorations. Only one patient needed an emergency arterial reconstruction; this man was admitted with acute cholecystitis and rest pain. While he was recovering from cholecystectomy, his aorta thrombosed and the patient required emergency aortofemoral bypass. Colon ischemia developed postoperatively and the patient died of septic complications related to the infarcted colon. Overall, eight deaths occurred in all groups, for a mortality rate of 22.8% (Table IV). All deaths occurred after primary aortic procedures; therefore, no deaths occurred as a result of primary biliary operations. Most deaths occurred in those patients who had emergency or urgent operations for infected grafts or symptomatic aneurysms. Most deaths were due to multisystem organ failure as a result of sepsis, coagulopathy, and myocardial infarction. In this group, the mortality rate was 55.5%. The patients who had elective procedures had a mortality rate of 11.1%, all caused by myocardial infarction. No deaths were due to ruptured aneurysms in patients with cholelithiasis who had their gallbladders removed first. There were no "true" ruptured aneurysms in any of these patients. There were no cases of acute cholecystitis and no emergency biliary procedures were performed in patients with gallstones who had aortic repair done first. DISCUSSION Biliary risks. The decision to perform any concomitant operation in patients needing aortic reconstruction should not be made without a clear understanding of the risks involved, not only the risks of doing the combined procedure but the risks of not doing it. Several studies have examined the natural history of untreated cholelithiasis. Wenckert and Robertson ~ described 781 cases of cholelithiasis followed up to 11 years without operation and found that 35% had biliary symptoms or complications. They also noted that the incidence of complications was twice as high (14% vs. 28%) in those patients

4 348 Fry and Fry Journalof VASCULAR SURGERY Table V. Type and number of complications in each group Group I: Group 11: Complications AAA AIOD/RAOD Myocardial infarct 2 ~ 1 ~ Bleeding (postop) 1 0 ARDS It 0 Sepsis/multisystem 2 ~ 3~1 - failure ARDS = adult respiratory distress syndrome. *Death. tlncludes one case of colon ischemia and two cases of acalculous cholecystitis. older than 60 years of age. The operative mortality rate was greater than 15% in the older group when treatment was delayed. A high incidence of complications was also noted by Lund 2 in his report of 526 patients followed up to 20 years with known cholelithiasis. Almost 70% of his patients had complications from untreated biliary disease and the operative mortality rate was 2.7% compared with 0.3% in those patients who had early operative treatment of the gallstones. Recent studies by Gracie and Ranohoff 3 and Thistle et al. 4 have shown a very low incidence of biliary complication in patients with asymptomatic cholelithiasis. In the study by Gracie and Ranohoff only 13% of 123 predominantly white male medical school faculty had biliary pain during the follow-up period of up to 13 years, whereas three patients (2.4%) required operation because of complications. The National Cooperative Gallstone Study showed a higher incidence of biliary pain in the initially asymptomatic group (33%), but the need for emergency operation was low (4%). 4 McSherry et al.s showed an equally low incidence of biliary problems in 135 patients with asymptomatic biliary disease followed up for 5 years. Only 10% of these patients had biliary colic and 7% needed an operation. In 556 symptomatic patients, 66% were able to tolerate their pain without intervention, s Ouriel et al. 6 and String 7 have examined the risk of late postoperative biliary problems in patients having both aortic disease and biliary lithiasis but in whom the gallbladders were not removed. They found a high incidence of early and late postoperative complications, including acute biliary sepsis. No additional deaths or morbidity occurred in those patients undergoing concomitant operations, with the exception of a graft infection incidence in the series reported by Ouriel et al. The contamination of the graft was said to be caused by failure of the surgeon to cover the graft with retro- peritoneal tissue before performing the chole~stectomy. On the basis of their experience, a policy of doing concomitant operations was encouraged. Postoperative acute cholecystitis has long been regarded as difficult to diagnose and potentially fatal in a large proportion of cases. Forttmatcly, this condition is rare, being estimated to occur only once in every 10,000 operations. 8 About one third of the cases arc acalculous infections and few sccm to occur in those patients with truly unsuspected gallstones. The Mayo Clinic reported only three cases of acute calculous cholecystitis after aortic procedures during a 17-year period. 8 Ouriel et al.9 had six cases of acalculous cholecystitis among 703 patients operated on for aneurysmal disease over a period of 16 years. 9 Our data support the rarity of acute postoperative biliary disease that requires emergency operation after aortic reconstruction. These data also confirm an increased risk in patients with sepsis and ruptured aneurysms; these patients have a high likelihood of acalculous rather than calculous inflammation. This finding may be due to the extreme hemodynamic instability and the massive blood replacement required during such difficult operations. In addition, lack of gallbladder stimulation from fasting and use of morphine analgesics have been implicated in the development of acalculous inflammation. 9 The incidence of common bile duct stones rises with age, reaching as high as 20% in patients older than 55 years of age) The same trend is also seen in the presence of bacteria in the bile--even in those persons in whom no ductal exploration is necded.11 The trend towards more complicated biliary disease and the greater risk of bacteria in the bile with age makes placement of a prosthetic graft risky at best. Aortic risks. Untreated aortic aneurysms have long been known to be associated with a high mortality rate because of rupture, averaging about 45% to 55% in most series. The overall risk of rupture is 25%, with a much higher rate for lesions more than 6 cm in diameter. 12 More recently, ccliotomy without aortic operation has been implicated in the origin of aneurysmal rupture13; this was attributed to activation of aortic collagenasc during the operation, which weakened the aneurysm wall further and precipitated rupture. No objective data were given to support this premise, and experiments on laboratory animals have shown no increased activity of aortic couagenase with abdominal operations not involving direct incision of the aorta) 4 Combined procedure risks. Several authors have examined the safety and desirability of combining nonvascular operations with an aortic procedure

5 Volume 4 Number 4 October 1986 Cholelithiasis and aortic reconstruction 349 Ochsner, Cooley, and DeBakey is in 1960 reported on a series of 931 aortic operations during which an associated procedure was performed. More than half of these were appendectomies (480 procedures) and 51 cholecystectomies were also listed. The overall mortality rate was less (5.8% vs. 8.6%) than in those patients in whom an aortic procedure only was done. No detailed description of medical risk, morbidity, or preoperative symptoms was given. In addition, the incidence of infected grafts or biliary disease was not stated. A benign experience was also reported by Tompkins et al.16; they reported on 15 patients who underwent combined procedures with a mortality rate of 9% and no graft infections. Ouriel et al. 6 and String 7 reported no increased mortality rates in their two series, although Ouriel et al. noted a graft infection rate of 2.2% in the combined group vs. no infections in those patients undergoing aortic repair alone. String 7 reported no graft infections but 33% of his patients had infected bile. A contrary point of view has been reported by Thomas et al. 17 and by Bickerstaffet al. is Both studies examined large groups of patients and showed markedly higher morbidity and mortality rates in patients who had concomitant biliary and aortic operations. In both series, the perioperative complication (including graft infection) and mortality rates were twice as high when a cholecystectomy was added. Our data suggest that combined procedures are rarely necessary. Patients who have both biliary and aortic disease can safely undergo "staged" procedures. The risk of postoperative cholecystitis after elective aortic reconstruction is extremely low, and the risk of aneurysm rupture is also low if the time between operations does not exceed 4 months. In most cases, an inflamed gallbladder is not usually safely removed in only 10 or 15 minutes. If the gallbladder can be removed so easily, the immediate need for cholecystectomy is questionable, especially in high-risk patients. Combined procedures should be done only in a very select group of patients in whom the size of the aneurysm and the severity of the biliary tract disease precludes staging of the procedures. The higher rates of common duct stones and infected bile in older persons should make the surgeon open the biliary tract with caution after placing a prosthetic graft. Lymphatic drainage of the biliary tree can go to periaortic nodes. Dissection at the level of the left renal vein will damage or lacerate some of these lymphatics and can expose the proximal anastomosis to potential contamination even with a reperitonealized graft. In situations in which a combined procedure is thought to be unavoidable, serious consideration should be given to doing a cholecystostomy to minimize the retroperitoneal dissection and the risk of contamination as well as to decrease operation time, fluid administration, and blood loss. A secondary cholecystectomy may be performed with low morbidity and mortality risks after the patient recovers from his primary operation. 19 CONCLUSIONS Combining aortic and biliary procedures may subject the patient to a higher risk of major complications (i.e., graft infection) and death than doing only the vascular procedure. Biliary procedures rarely need to be combined with an aortic reconstruction. Unsuspected and asymptomatic gallstones found at operation need not be removed because the subsequent risk of acute cholecystitis is low. Patients with biliary colic and aneurysms may safely undergo staged procedures if they are carefully followed up, and if the time between a primary biliary operation and subsequent aortic reconstruction does not exceed 4 months. Operative planning should depend on which of the two conditions is thought to put the patient at highest risk if left untreated. Concomitant operations should be done only in patients in whom the risk of leaving either condition untreated is greater than the risks of performing both operations. Performance of cholecystostomy instead of cholecystectomy may reduce operating time, the need for dissection, and the probability of graft contamination in those cases in which concomitant operations are done. REFERENCES 1. Wenckert A, Robertson B. The natural course of gallstone disease: Eleven year review of 781 nonoperated cases. Gastroenterology 1966;50: Lund J. Surgical indications in cholelithiasis. Ann Surg 1960;151: Gracie WA, Ranohoff DF. The natural history of silent gallstones: The innocent gallstone is not a myth. N Engl J Med 1982;307: Thistle JL, Cleary PA, Lachin JM, et al. The natural history of cholelithiasis: The National Cooperative Gallstone Study. Ann Intern Med 1984;101: McSherry cr, Ferstenberg H, Calhoun WF, et al. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann Surg 1986;202: Ouriel K, Ricotta JJ, Adams JT, et al. Management of cholelithiasis in patients with abdominal aortic aneurysm. Ann Surg 1983;198: String ST. Cholelithiasis and aortic reconstruction. J VASC SURG 1984;1: Devine RM, Farnell MB, Mucha P. Acute chole~stitis as a

6 350 Fry and Fry Journal of VASCULAR SURGERY complication in surgical patients. Arch Surg 1984;119: Ouriel K, Green RM, Ricotta JJ, DeWeese JA, Adams JT. Acute acalculous cholecystitis complicating abdominal aortic aneurysm resection. J Vase SURG 1984;1: Cahow Jr EH, Glenn F. Sequelae attributed to delayed surgical treatment of gallstones.. Ann Surg 1965; 161: Farnell MB, van Heerden JA, Beart RW. Elective cholecystectomy: The role of biliary bacteriology and administration of antibiotics. Arch Surg 1981;116: Rutherford RB. Infrarenal aortic aneurysms. In: Rutherford RB et al, ecls. Vascular surgery. Philadelphia: WB Saunders Co, 1984: Swanson RJ, Littooy FN, Hunt TK, et al. Laparotomy as a precipitating factor in the rupture of intra-abdominal aneurysms. Arch Surg 1980;115: Cohen JR, Perry MO, Hariri R, Holt J, Alvarez O. Aortic collagenase activity as affected by laparotomy, cecal resection, aortic mobilization, and aortotomy in rats. J VASC SURG 1984;1: Ochsner JL, Cooley DA, DeBakey ME. Associated intra-abdominal lesions encountered during resection of aortic aneurysms. Dis Colon Rectum 1960;3: Tompkins WC, Chavez CM, Conn JH, et al. Combining intra-abdominal arterial grafting with gastrointestinal or biliary procedures. Am J Surg 1973;126: Thomas JH, McCroskey BL, Iliopoulos JI, et al. Aortoiliac reconstruction combined with nonvascular operations. Am J Surg 1983;146: BickerstaffLK, Hollier LH, Van Peenen HJ, et al. Abdominal aortic aneurysm repair combined with a second surgical procedure--morbidity and mortality. Surgery 1984;95: Weigelt JA, Norcross IF, Aurbukken CM. Cholecystectomy after cholecystostomy. Am J Surg 1983;146: CORRECTION In the special article, "Suggested Standards for Reports Dealing With Lower Extremity Ischemia," prepared by the Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery (J VASC SVRG 1986;4:80-94), on page 85, parts A and B of Fig. 1 are reversed. The correction has been made in reprints.