ChoMithiasis and aortic reconstruction

ChoMithiasis and aortic reconstruction S. Timothy String, M.D., Mobile, Ala. Identification of cholelithiasis during abdominal aortic reconstruction with placement of a vascular prosthesis provides cause for hesitation in performing a simultaneous cholecystectomy because of the potential contamination of the graft. However, the association of cholelithiasis with cholecystitis is well established and was observed in a group of patients who had known cholelithiasis following aortic reconstruction. Cholelithiasis was noted in 50 of 250 patients who underwent reconstruction of the abdominal aorta or its major branches. Seventeen of the 50 patients with cholelithiasis underwent a cholecystectomy prior to aortic reconstruction. Sixteen patients underwent a cholecystectomy at the time of aortic reconstruction and experienced no morbidity related to the cholecystectomy. Seventeen patients with cholelithiasis did not undergo cholecystectomy. All were asymptomatic. Nine of these individuals developed cholecystitis or symptoms related to their gallstones following aortic reconstruction. A subsequent cholecystectomy was performed in all nine patients. The interval between aortic reconstruction and cholecystectomy was from 2 weeks to 108 months. The remaining eight patients with cholelithiasis have been followed up for 17 to 50 months. Six of these patients remain asymptomatic. The two patients followed up for the longest period (42 and 50 months, respectively) have become symptomatic. If there are no mitigating circumstances, cholecystectomy is advised for patients undergoing aortic reconstruction with associated cholelithiasis. (J VASC SURG 1984; 1:664-9.) Identification of cholelithiasis during abdominal aortic reconstruction provides cause for hesitation in performing a simultaneous cholecystectomy because of the potential contamination of the vascular prosthesis. Cultures of gallbladder mucosa and bile have been reported to be positive in up to 46% of cholecystectomies. 1 However, the association of chomithiasis with cholecystitis is well established 2,3 and was observed in a group of patients who had known cholelithiasis following aortic reconstruction. PATIENTS AND MATERIAL Two hundred forty-eight patients who underwent reconstruction of the abdominal aorta or its major branches between 1978 and 1982 were reviewed to determine the clinical course of cholefithiasis in this population with aortic disease. Two additional patients had undergone resection of an abdominal aneurysm in 1972 and 1977, respectively. These two individuals had gallstones at the time of the aneurysmectomy and were included in the series, for a total of 250 patients. This group of patients underwent a variety of From the Department of Surgery, Mobile Infirmary. Presented at the Thirty-seventh Annual Meeting of the Sodety for Vascular Surgery, San Francisco, Calif., June 17-18, 1983. Reprint requests: S. Timothy String, M.D., Vascular Surgery, P.C., 171 Louiselle St., Mobile, AL 36607. 664 vascular reconstructive procedures of the abdominal aorta or its major branches. Abdominal aortic aneurysmectomy was performed in 107 patients. Aortic-iliac-femoral arterial occlusive disease was corrected by aortofemoral bypass in 90 individuals and by aortoiliac bypass in 28 patients. Renal artery reconstruction was the primary procedure in the remaining 17 individuals of the group of 250 patients. Thirteen patients underwent a renal artery or superior mesenteric artery reconstruction in association with the primary aortic procedure. Fifty patients of the group of 250 were noted ~. have chomithiasis. The age range was from 51 to 82 years, and there was a 2:1 ratio of men to women. Seventeen of those with cholelithiasis had been symptomatic from the gallstones prior to the aortic reconstruction and had undergone a cholecystectomy. The gallstones of the remaining 33 patients were noted during abdominal exploration at the time of the aortic reconstruction--except in one patient. These 33 patients either underwent a concomitant cholecystectomy with the aortic reconstruction or retained the gallstones by not undergoing a cholecystectomy during aortic reconstruction. RESULTS Cholefithiasis was identified in 33 patients during abdominal exploration at the time of the aortic reconstruction--in all but one patient. Preoperative

Volume 1 Number 5 September 1984 Cholelithiasis and aortic reconstruction 665 Table I. Aortic procedures with concomitant cholecystectomy Procedure No. of patients Abdominal aorv_ic aneurysm 9 Aortofemoral bypass 5 Aortoiliac bypass 1 Aortofernoral bypass with femoropopliteal bypass 1 evaluation of the gallbladder was not routinely performed unless the patient had symptoms of cholelithiasis. Although an SMA20 was obtained preoperatively for each patient, ultrasound examination of the gallbladder or an oral cholecystogram were performed only when symptoms dictated. Ultrasound examinations were performed on those patients with abdominal aortic aneurysms. However, ultrasound ~Z this instance was unreliable for the detection of cholelithiasis, since the gallbladder was not specifically scanned in conjunction with the aorta. Sixteen patients underwent a concomitant cholecystectomy with the aortic reconstruction. The types of aortic reconstructive procedures performed in these 16 patients are listed in Table I. The ages of this group ranged from 51 to 82 years; 11 were men and five women. Three of these patients had been symptomatic from their cholelithiasis prior to the aortic procedure and had known gallstones. The gallstones of the remaining 13 patients were found coincidentally during abdominal exploration. These patients were asymptomatic. The concomitant cholecystectomy was performed after the aortic reconstruction and reperitonealization of the aorta. The gallbladder area was then isolated with surgical packs prior to cholecystectomy. ~Eare was exercised to avoid perforation of the gallbladder when the cholecystectomy was performed. None of the gallbladders ruptured or exhibited bile leakage during the cholecystectomy. A Boyle electrocautery (Davol, Cranston, R.I.) was used to transect the ligated cystic duct. Routine cultures were obtained from the bile of these gallbladders with a positive growth in 33% of the patients. No antibiotic solutions were used for irrigation of the retroperitoneum or gallbladder bed. Only normal saline solution was used for irrigation. The gallbladder bed was neither drained nor closed but left open in all cases. None of the patients developed an intra-abdominal infective process or other morbidity related to the cholecystectomy. This finding is similar to the results of patients who had concomitant cholecystectomy with graft placement as reported by._ 5 B Q. 1 ' 21 6 B 7 m m m 8 9 L 0 ' 1'2 " 6'0 v'2 8'4 9'6 160 months Fig. 1. Bar graph depicting time interval between aortic reconstruction and subsequent cholecystectomy. 1 ASYMPTOMATIC [] SYMPTOMATIC ~5 06 II Q'7 7/lllllllllllllllllllll/lllllllll/lll////J 8 ~//I////t111111/1111111111111IIIIIIII//111111/I//] I 0 1 '2 2'4 3'6 4'8 6'0 months Fig. 2. Bar graph demonstrating follow-up (in months) for those patients whose cholelithiasis was noted during aortic reconstruction. Tompkins et al. 4 and Ochsner et al.5 Systemic cefazolin sodium was routinely administered pre- and postoperatively for all aortic reconstructions. There was one death in this group: from a myocardial infarction that occurred 4 days postoperatively. The gallbladders removed in the 16 patients were interpreted as chronic cholecystitis in 14. No gallbladder pathology was noted in the remaining two patients, but their gallbladders were observed to contain multiple stones. Seventeen patients retained their gallstones since a cholecystectomy was not performed during the aortic reconstruction. All the patients in this group have been followed up postoperatively. Nine developed symptoms referable to cholelithiasis in the ensuing months. These nine patients ranged in age from 52 to 73 years, and the male-to-female ratio was 7: 2. The follow-up period averaged 25 months. Subsequent cholecystectomies were performed at 2 weeks and from 6 to 108 months (Fig. 1). Eight of the nine patients had stones palpated during the preceding aortic reconstruction. One of the patients, who had acute cholecystitis and a subsequent cholecystectomy 13 months following an aortic reconstruction, did not have gallstones noted during the aortic procedure. However, many stones of varying size were observed in the gallbladder at the time

666 String Journal of VASCULAR SURGERY of cholecystectomy. Eight patients had acute cholecystitis, and one had subacute symptoms. The remaining eight of the 17 patients with nonoperated cholelithiasis have been followed up for an average of 32 months (range 17 to 50 months) (Fig. 2). This group ranges in age from 53 to 73 years and comprises five men and three women. Six of these patients remain asymptomatic. However, the two patients followed up for the longest period (42 and 50 months) have developed symptoms referable to their cholelithiasis but have not had surgery. DISCUSSION The incidence of cholelithiasis determined at autopsy for the general population over 50 years of age ranges from 19% to 24%. 6,7 The 248 consecutive patients reviewed had a similar incidence of cholelithiasis (19%). The two patients with known cholelithiasis added to the series following aortic reconstruction in 1972 and 1977 were not included in this percentage. This atherosclerotic population does not appear to be at any greater risk for cholelithiasis than does the general population over 50 years of age. Symptoms referable to gallstones were present in all 17 patients who had undergone a cholecystectomy prior to aortic reconstruction. None of these patients had developed symptoms or problems related to their biliary function following cholecystectomy. The aneurysm or symptomatic arterial occlusive disease had developed in the years subsequent to the cholecystectomy. If preoperative knowledge of cholelithiasis is desired, the ultrasonographer must be directed to survey the gallbladder. Routine scanning of the aorta will not necessarily include visualization of the gallbladder. This, of course, will vary from institution to institution, as well as with the individual ultrasonographer's philosophy on how inclusive an aortic ultrasound examination should be. Ultrasonography of the aorta failed to include the gallbladder in the majority of our cases. A thorough abdominal exploration is equally important for the establishment of a diagnosis of cholelithiasis. Gallstones were not palpated during aortic reconstruction in one patient who developed acute cholecystitis, which necessitated a cholecystectomy 13 months later. Because multiple stones of varying size were identified after removal of this gallbladder, it seems unlikely that they were formed during this relatively short time interval. It is more probable that the stones were missed on abdominal exploration. It is important to determine not only the pres- ence of cholelithiasis intraoperatively but also the size of the common duct for the suspected presence of intraductal stones, if a concomitant cholecystectomy is anticipated. If common duct stones or ductal enlargement is identified, it would appear to be more expedient to return another day rather than expose the intraductal system. This exposure would provide an increased potential for bacterial contamination, as well as the increased morbidity associated with common duct exploration.1 Meticulous attention to preserving an intact gallbladder is also important to prevent spillage of possibly contaminated bile. The procedure increased the length of anesthesia time from 10 to 15 minutes. No cholecystectomies were performed with ruptured ancurysms. Serious cardiac arrhythmias, anesthetic problems, and unexpected difficulties with the aortic reconstruction precluded a simultaneous cholecystectomvz Although no antibiotic irrigation solutions were used, no infective processes of the abdominal cavity, retroperitoneum, graft, or wound were encountered. Ce?azolin sodium was intravenously administered routinely pre- and postoperatively in all aortic reconstructions. Chethn and Elliott s reported that pre- and postoperative antibiotics did not reduce the incidence of positive bile cultures (53%) in biliary surgery, but the antibiotics did reduce invasive infections from 27% to 4%. All patients with a concomitant cholecystectomy had a Dacron graft incorporated as part of the aortic reconstruction. No other form of morbidity directly related to the cholecystectomy such as bile leakage or common duct abnormalities was encountered in the 16 patients undergoing a concomitant cholecystectomy. Cholangiography was not performed and is not recommended. Acalculous cholecystitis has been reported by Arnold 9 to occur in 7% of those undergoing cholecystectomies. One of the 250 patients reviewed did undergo a cholecystectomy for acute acalculous cholecystitis following aortic reconstruction. He was not included in the series of 50 patients with cholelithiasis. Acute calculous cholecystitis in the immediate postoperative period can have a grave consequence; a mortality rate of 47% was reported by Ottinger. 1 This problem was not encountered in the immediate postoperative period by patients in this series. The earliest occurrence was 2 weeks postoperatively. Seven of the nine patients undergoing subsequent cholecystectomy developed significant acute gallbladder symptoms within 14 months of aortic reconstruction. The natural history of cholelithiasis can pr,:

Volume 1 Number 5 September 1984 ChoIelithiasis and aortic reconstruction 667 duce acute or chronic symptoms, and the percentage of those becoming symptomatic has been reported to vary between 35% and 45%. 2,a The nine of 17 patients in this series with known cholelithiasis who were followed up, became symptomatic, and required cholecystectomy constitute a somewhat higher percentage than that of the previously reported series. Perhaps the higher percentage of patients developing symptoms in our series is due to the older age group or the results of a previous abdominal procedure. It is also noteworthy that the two patients followed up for the longest time intervals have become symptomatic. Although no serious morbidity was encountered with any of the patients requiring subsequent cholecystectomy, the reported mortality rate from a cholecystectomy varies from 1.5% for those with c~'onic symptoms to 3.5% for those with acute symptoms; the postoperative complication rate is 4%. 9 These figures apply for all age groups. The older age of this group of patients under discussion becomes an important consideration with regard to cholecystectomy. Glenn 11 and associates noted that the mortality rate for biliary surgery increased with age and almost doubled (from 5.2% to 9.3%) for those 65 years of age or older. The morbidity associated with delayed surgical treatment increased from 14% for those under 60 years of age to 28% for those over 60 years of age as reported by Wenckert and Robertson? In addition, emergency and semiemergency surgery in the older patient carries an attendant risk? 2 The more advanced age of those undergoing aortic reconstruction and the progression of asymptomatic chomithiasis to symptomatic chomithiasis are compelling factors to con- :;der a simultaneous cholecystectomy when cholelithiasis is identified during aortic reconstruction. SUMMARY If no mitigating circumstances are present, concomitant cholecystectomy is advised in those pa- tients undergoing aortic reconstruction with associated cholelithiasis. This recommendation is based on the finding that more than half of those patients followed up with cholelithiasis after an aortic reconstruction required a cholecystectomy because of acute or chronic symptoms. The combination of these procedures eliminates future cholecystitis, its attendant morbidity, and the necessity of an additional operative procedure, and does not increase morbidity related to cholecystectomy. REFERENCES 1. Fukunaga FH. Gallbladder bacteriology, histology, and gallstones: Study of unselected cholecystectomy specimens in Honolulu. Arch Surg 1973; 106:169-71. 2. Comfort MW, Gray HK, Wilson JM. The silent gallstone: A 10 to 20 year followup study of 112 cases. Ann Surg 1948; 128:93i-7. 3. Wenckert A, Robertson B. The natural course of gallstone disease: Eleven-year review of 781 nonoperated cases. Gastroenterology 1966; 50:376-81. 4. Tompkins Jr WC, Chavez CM, Conn JH, Hardy JD. Combining intra-abdominal arterial grafting with gastrointestinal or biliary tract procedures. Am J Surg 1973; I26:598-600. 5. Ochsner JL, Cooley DA, DeBakey ME. Associated intraabdominal lesions encountered during resection of aortic aneurysm. Dis Colon Rectum 1960; 3:485-90. 6. Newman HF, Northup JD, Rosenblum M, Abrams H. Complications of cholelithiasis. Am J Gastroenterol 1968; 50:476-96, 7. Schein CJ. Acute choleeystitis: Clinical diagnosis. New York: Harper & Row, Publishers, 1972:69-70. 8. Chetlin SH, Elliott DW. Preoperative antibiotics in biliary surgery. Arch Surg 1973; 107:319-23. 9. Arnold DJ. Cholecystectomies in Ohio: Results of a survey in Ohio hospitals by the Gallbladder Survey Committee, Ohio Chapter, American College of Surgeons. Am J Surg 1970; 119:714~7. 10. Ottinger LW. Acute cholecystitis as a postoperative complication. Ann Surg 1976; 184:162-5. 11. Glenn F. Trends in surgical treatment of calculous disease of the biliary tract. Surg Gynecol Obstet 1975; 140:877-84. 12, Harbrecht PJ, Garrison RN, Fry DE. Surgery in elderly patients. South Med J 1981; 74:594-8. DISCUSSION Dr. Cornelius Olcott IV (Palo Alto, Calif.). I believe Dr. String's excellent paper raises two important questions. First, what is the risk of not removing gallstones at the time of aortic reconstruction? Second, is cholecystectomy a safe procedure when it is combined with the installation of prosthetic graft material? My partner Dr. John Mehigan and I reviewed our,perience of approximately 400 aortic reconstructive procedures performed at Stanford University Hospital since 1978. Interestingly enough, the incidence of gallbladder disease was very similar to Dr. String's. Eighteen percent of our patients had cholelithiasis. Unlike Dr. String's experience, two thirds of our patients had had a previous cholecystectomy prior to their aortic reconstruction. In a third of the cases, gallstones were found at the time of aortic surgery. In this latter group there was not a

668 String lournal of VASCULAR SURGERY single incidence of acute biliary tract disease during the immediate postoperative period. We looked more closely at a group of 100 consecutive patients undergoing aortic reconstruction over a 13-month period beginning in January 1980. These patients were followed up to the present time, Six patients in this group were noted to have cholelithiasis at the time of aortic surgery. Only one of these patients subsequently developed cholecystitis, and this occurred 11 months postoperatively. Again, none of the patients developed acute problems in the immediate postoperative period. At least from our viewpoint, we do not believe that leaving gallstones behind at the time of aortic reconstruction poses a real problem to the management of patients in the postoperative period. With regard to the safety of removing the gallbladder in conjunction with an aortic reconstructive procedure, obviously we cannot testify to that from our experience since we have not performed any concomitant cholecystectomies. I know that Dr. String is a very safe and careful surgeon, and obviously he was able to perform concomitant cholecystectomy without any break in technique; but he did have a 33% incidence of infected bile. I think if this general philosophy were adopted by all surgeons, one would note an increase in postoperative intra-abdominal infections. Dr. Stoney has demonstrated that late graft infections can appear up to 12 years later. Obviously, this must be a real concern. I would like to make two points. First, I think we should be hesitant in adopting an aggressive attitude of performing cholecystectomy at the time of aortic reconstrucrion. Second, I would like to ask Dr, String to return in 4 or 5 years and bring us up to date. I think it would be important to know whether late graft infections occur in this group. Dr. John J. Ricotta (Rochester, N.Y.). I would like to congratulate Dr. String on his paper and offer some evidence from our own institution to support his claims. We reviewed 42 patients who had coexisting aortic aneurysm and gallbladder disease and were seen at the University of Rochester between 1966 and 1982. These patients represented 4.9% of all patients we saw during that period with aneurysms. We had 18 patients who underwent simultaneous aneurysmectomy and cholecystectomy, 11 patients who had aneurysmectomy alone, and 13 patients who had cholecystectomy alone. These latter patients (the 11 with aneurysmectomy alone and the 13 with cholecystectomy alone) presented with acute gallbladder disease. In the group with simultaneous aneurysmectomy and cholecystectomy, only one patient developed a late graft infection (24 months postoperatively). This patient had had the gallbladder removed before the retroperitoneum was closed and also had undergone a gastrostomy. In none of the other 17 patients who subsequently underwent surgery was there any evidence of graft infection. Interestingly, in the 11 patients who had aortic aneurysm resection alone, two developed acute biliary tract complications in the postoperative period and one died of biliary sepsis. Of the remaining nine patients, seven developed acute cholecystitis in late follow-up. This leads me to ask Dr. String three questions. First, has he experienced any acute postoperative complications attributable to biliary tract disease in patients in whom the gallbladder was left in? Second, how does he feel about cholecystectomy in urgent aortic reconstructions? Both patients in our resection group who developed complications when the gallbladder was not removed had undergone urgent aortic aneurysm resection. Finally, how does he feel about aortic aneurysm resection or aortoiliac reconstruction when the patient has symptomatic gallbladder disease? Dr. George E. Pierce (Kansas City, Kan.). We recently reviewed our experience in performing nonvascular intra-abdominal procedures in combination with aortoiliac reconstruction at the University of Kansas. Over a 6-year period from 1975 to 1981, we performed synchronous nonvascular procedures in 76 of 521 patients with either emergency or elective aortoiliac ceconstruction for aneurysmal or occlusive disease. Cholecystectomy was the most common procedure and was performed in 39 of the 76 patients in this group. In general, our findings are in agreement with Dr. String's. Only one complication could be directly attributed to the cholecystectomy: herniation of the small bowel through a drain site. There were no graft infections in the cholecystectomy group. In fact, the only case of graft infection in the entire group occurred in a patient with aortoiliac reconstruction only. These results, however, should not be misinterpreted to support a cavalier approach to combining nonvascular procedures with aortoiliac reconstruction. The mortality rate for patients with combined nonvascular and vascular procedures was no different from that for the group with aortoiliac reconstruction alone, but the overall complication rate was higher (17% vs. 10%). Although this was not statistically significant, it does raise some concern. Furthermore, it should be pointed out that our study, like Dr. String's, was a retrospective study of a selected group of patients. For example, it does not include patients in whom elective aortoiliac reconstruction was deferred following open gastrointestinal procedures. In some cases it may be very difficult to determine whether the potential benefits of combining nonvascular procedures with aortoiliac reconstruction outweigh the potential risks. Dr. String (closing). Dr. Olcott, I think it is interesting to learn that two thirds of your patients underwent cholecystectomies in the preoperative period. I guess that we are just a little slow in performing cholecystectomies in Mobile. Your point concerning possible future infections is something to be considered. One patient from this series developed a graft infection 4 years after graft placement. A subsequent cholecystectomy was performed 2 years later. No particular association of these two procedures was found. No correlation existed between the culture from

Volume 1 Number 5 September 1984 Cholelithiasis and aortic reconstruction 669 the infected graft and that from the gallbladder taken at the time of the cholecystectomy. I would like to ask Dr. Ricotta a question concerning the patient with the infection. Was the organism the same as that cultured from the gallbladder, or was there a negative culture at the time of cholecystectomy? Acute postoperative cholecystitis was not encountered in our series. The earliest case of cholecystitis occurred at 2 weeks. The patient had been discharged. The excellent point concerning urgent vascular reconstructions must be emphasized since none of our cholecystectomies was performed with ruptured abdominal aortic aneurysms. As was noted, mitigating factors were mentioned. One mitigating factor is a ruptured aneu- rysm. In addition, meticulous technique with regard to the cholecystectomy after aortic reconstruction is most important. With regard to symptomatic patients, we think that if the vascular reconstruction goes well and there are no mitigating factors, then the patient's gallbladder should be removed at the time of aortic reconstruction. Dr. Pierce, we can only concur heartily with you that this presentation is certainly not a license to remove everyone's gallbladder. A cavalier approach should not be taken. Meticulous technique and sound clinical judgment must be exercised when cholelithiasis is noted during aortic reconstruction.