Introduction

The first heart transplantation was performed in 1967 and the patient survived 18 days¹. The advances in perioperative care and immunosuppressive treatment resulted in a significant increase in survival of transplant patients². This increase caused the development of transplant-related diseases, and the diagnosis and treatment of conditions that are prevalent in the general population had to be adapted to these patients.

The prevalence of gallbladder stones in transplant patients is higher than in the general population³ due to factors that promote lithogenesis, such as immunosuppressants (cyclosporine, tacrolimus), obesity, weight variations and diabetes^3-6. The risk of complications associated with immunosuppressants and abnormal ventricular function complicates defining the optimal timing for cholecystectomy.

The aim of this study is to analyze and describe the results obtained in cholecystectomies in heart transplant patients.

Material and Methods

We conducted a retrospective descriptive study of heart transplant patients > 18 years who underwent laparoscopic cholecystectomy between January 1994 and December 2017 at Hospital Cosme Argerich.

We selected patients by cross-referencing the databases of heart transplantation and scheduled biliary surgeries. We identified patients with a history of transplantation and collected information on their medical history, clinical parameters and laboratory tests at the time of biliary surgery, the time interval between transplantation and cholecystectomy, indication for cholecystectomy, intraoperative cholangiography (IOC), presence of choledocholithiasis, postoperative length of stay in the intensive care unit, conversion to open surgery, postoperative complications, readmission rate and mortality.

Statistical data analysis was performed using Microsoft Excel 2010^®. Qualitative variables are expressed as percentage and quantitative variables are expressed as mean ± standard deviation or median and interquartile range, according to their distribution.

An informed consent was not required due to the retrospective nature of the study.

Results

Between January 1994 and December 2017, 154 heart transplant procedures were performed (112 men and 2 women). Mean age was 40 years (30- 53). Of these patients, 16 underwent laparoscopic cholecystectomy after hear transplantation. The time interval between transplantation and cholecystectomy ranged between 4 and 180 months.

The clinical characteristics and indications for transplantation are described in Tables 1 and 2.

Table 1 Clinical history and indications for heart transplantation (n=16). 

Table 2 Characteristics of laparoscopic cholecystectomy in 16 patients with heart transplantation 

The immunosuppressants used were cyclosporine 50%, mycophenolate 33%, everolimus in 2 patients and azathioprine in 1.

All the patients corresponded to ASA (American Society of Anesthesiologists) physical status classification grade 3.

The predictors of choledocholithiasis (alkaline phosphatase and gamma glutamyl transferase) were increased in 88% of the patients.

The main indications for cholecystectomy were symptomatic cholelithiasis (38%), acute cholecystitis (47%) and bile duct obstruction (15%) diagnosed by clinical criteria, ultrasound and laboratory tests before surgery. All the patients underwent laparoscopic cholecystectomy; one patient required conversion to open surgery due to multiple adhesions.

Intraoperative cholangiography was performed in 100% of the cases, and two patients (11%) presented choledocholithiasis that was managed with transcystic instrumentation using a Dormia basket.

Six patients (37.5%) required admission to the intensive care unit after surgery with men length of stay of 1.7 days (range 0-4).

There were no postoperative complications, readmissions or mortality on the series.

Discussion

In our series, mean age was 44 years, and most patients were male (62%), as opposed to the published literature^5,7. All these patients should undergo abdominal ultrasound during evaluation and follow-up to detect gallbladder stones and avoid related complications^4,8,9.

In a series of 509 patients, 22% underwent cholecystectomy (13% before transplantation and 9% after transplantation)⁸. Although there is no consensus about the timing for performing the intervention, several studies have shown that laparoscopic cholecystectomy is safe and effective in these patients.

To our knowledge, there are no studies comparing the safety of cholecystectomy before or after transplantation. Cholecystectomy before transplantation should be considered in clinically stable patients ^8,10.

All these patients should undergo abdominal ultrasound during evaluation and follow-up to detect gallbladder stones and avoid related complications^4,6,11; prophylactic cholecystectomy after surgery is an option⁹.

The percentage of cholelithiasis in our study (11%) was lower than in other series (19.5%)⁵.

The immediate postoperative period after transplantation has the highest rate of morbidity and mortality; therefore, in these cases it is better to carry out a less invasive procedure (percutaneous cholecystostomy, endoscopic retrograde cholangiopancreatography, etc.) until ventricular function improves enough to allow performing cholecystectomy⁸.

Cholecystectomy before transplantation is difficult since most patients require acute transplantation and their ventricular function is a contraindication to cholecystectomy.

These results show that laparoscopic cholecystectomy in heart transplant patients is safe, even in cases of acute cholecystitis and choledocholithiasis. Other studies show higher rates of morbidity and mortality^4,8 and one large series reported a mortality rate up to 2.2%¹⁰.

The preoperative evaluation and postoperative complications of transplant patients are similar to those of the general population.

Conclusions

The possibility of developing biliary complications leads to performing cholecystectomies in asymptomatic patients; therefore, abdominal ultrasound is recommended for the early detection of gallbladder stones.

Cholecystectomy before transplantation is difficult since most patients require acute transplantation and their ventricular function is a contraindication to cholecystectomy.

Laparoscopic cholecystectomy is safe and is the method of choice for heart transplant patients with cholelithiasis. Intraoperative cholangiography should be performed as the predictors of choledocolithiasis are usually abnormal.