Biliary complications after cardiovascular procedures

Objective

Biliary complications after cardiopulmonary bypass procedures are infrequent but they carry a significant incidence of morbidity and mortality. The aim of this study was to ascertain the frequency of biliary complications following open heart surgery, to determine possible preoperative risk factors and to identify that early diagnosis and prompt institution of therapy are the most important factors to improve the outcome.

Materials and methods

Within 3 years, all patients (n = 4588) who had undergone open heart surgery for a variety of cardiac lesions were attended at the ICU of our institution and were examined retrospectively for complications involving the gall bladder and biliary tract. All case histories of the patients were subjected to meticulous analysis. Patients with an indication of hepatic dysfunction, jaundice or biliary disorders were excluded from this study.

Results

Biliary complications occurred in 14 patients, 12 of whom had to undergo subsequent abdominal surgery. Gangrene and perforation of gallbladder was the most common complication (n = 5), followed by acute acalculous cholecystitis (n = 4), distension of common bile duct without indications of biliary stasis and presence of sludge (n = 3), cholelithiasis (n = 1) and empyema (n = 1). The majority of patients presented within the third postoperative week (21 ± 11 postoperative days). Clinical and laboratory findings included a distended abdomen, elevated white blood cells, elevated C-reactive protein and lactate levels, nonspecific changes in the liver function chemistries and unexplained sepsis. A specific preoperative diagnosis was established in 13 patients (93%). Cholecystectomy was performed in five patients and percutaneous drainage of gallbladder in seven patients. Two patients responded well to conservative measures and diagnostic laparotomy was avoided. Five patients had gangrenous gallbladders, with frank perforation in two. The mortality rate was 43%. Biliary complications correlated significantly with advanced age (66 vs 63.5 years), the male sex (men/women: 10/4), combined cardiac surgical procedures (CABG ± valve replacement), preoperative low cardiac output syndrome (EF < 45%), prolonged bypass time (170 vs 107 min), aortic cross-clamp time (129 vs 68 min) and mechanical ventilation (>48 hours), the usage of IABP, multiple transfusions, systemic inflammatory response syndrome, visceral hypoperfusion and ischemia, and the administration of inotropes and other medications.

Conclusion

Biliary complications after cardiac surgery are uncommon but life-threatening and may result from hypoperfusion of the gallbladder due to various factors. Clinical features are often subtle, and a high index of suspicion is necessary for an early diagnosis and for the institution of appropriate treatment. Delay of operative management on the grounds of recent cardiac surgery is not justified and is accompanied by an unacceptable mortality rate.