Biliary sludging in critically ill trauma patients

Incidence and risk factors of acute cholecystitis after cardiovascular surgery

OBJECTIVES

Acute cholecystitis is a complication in critically ill patients. However, a few studies have described its incidence, risk factors, and mortality in patients who underwent cardiovascular surgery. We investigated the incidence, perioperative predictors, and clinical features of acute cholecystitis after cardiovascular surgery.

METHODS

This retrospective cohort study examined 7013 patients who underwent cardiovascular surgery between October 2000 and March 2019 at a tertiary care hospital. We collected preoperative, intraoperative, and postoperative data from our database and electronic medical records. The primary outcome was the incidence of postoperative cholecystitis until hospital discharge. A multivariable logistic regression analysis to estimate perioperative predictors of acute cholecystitis was conducted. We described the clinical characteristics of patients complicated with acute cholecystitis.

RESULTS

Among the 7013 patients, 51 (0.7%) developed acute cholecystitis. Logistic regression analysis found that circulatory arrest (odds ratio [OR] 1.97; 95% confidence interval [CI] 1.04-3.74; P = 0.037) and intraoperative massive transfusion (OR 2.03; 95% CI 1.03-4.01; P = 0.041) were associated with the incidences of cholecystitis. In-hospital mortality was significantly higher in the cholecystitis group than in the non-cholecystitis group (13.7% vs 3.9%, P = 0.004). Aortic disease was more frequent in the cholecystitis group (54.9% vs 38.6%, P = 0.021). The median time of acute cholecystitis onset from surgery was 12.5 days (interquartile range 7.0-27.75). Twenty-six patients (51.0%) developed asymptomatic cholecystitis.

CONCLUSIONS

Approximately 1% of patients who underwent cardiovascular surgery developed postoperative cholecystitis; half of them were asymptomatic. Since cholecystitis is associated with high mortality, it is a complication after cardiovascular surgery that needs to be considered.

Endoscopically obtained bile aspirate is an accurate adjunct in the diagnosis of symptomatic gallbladder disease

Endoscopically obtained bile aspirate was found to be an effective technique to identify patients with symptomatic gallbladder disease and negative diagnostic studies.

Objectives:

The experience of a single surgeon in a rural hospital over a 10-year period was analyzed with respect to the utilization of endoscopically obtained bile aspirates as an adjunct in the diagnosis of symptomatic gallbladder disease.

Methods:

A retrospective study of the author's entire cholecystectomy experience over a 10-year period with 641 patients was conducted to evaluate the utility of the bile aspirate in the preoperative selection of operative candidates and with respect to the ultimate pathologic diagnostic accuracy of the test.

Results:

Derivation of preoperative diagnosis via traditional standard means was possible in 479 patients. An endoscopically obtained positive bile aspirate was found in 162 additional patients who failed to have positive traditional diagnostic studies (acalculous gallbladder disease). Micro-pathology was determined to be present in 603 patients (94.07%). In 27 of the 38 negatives, there had been positive radiological studies (71%). In 11 of the 38, a positive preoperative bile aspirate had been obtained (28.9%). Of the 162 patients with a positive bile aspirate, 151 (93.21%) of the gallbladder specimens had confirmatory histologic analysis (92.1% confidence interval ± 3.95%).

Conclusion:

In patients with symptoms suggestive of clinical gallbladder disease and negative traditional diagnostic studies, the endoscopically obtained bile aspirate has been shown to be a highly reliable tool in establishing the diagnosis and is recommended as an aid in the appropriate selection of candidates who may benefit from cholecystectomy.

Continuous enteral feeding impairs gallbladder emptying in infants

OBJECTIVE

The objective was to test the hypothesis that continuous enteral feeding impairs gallbladder emptying in infants.

STUDY DESIGN

A prospective crossover study was performed in 15 infants: (1) bolus enteral feeds were given in phase A, (2) a continuous milk feed was given for 3 days in phase B, and (3) bolus feeds were resumed in phase C. The gallbladder was studied with ultrasonography in phase A, on days 1 and 3 of phase B, and at the start and on days 2 and 4 of phase C.

RESULTS

Baseline volume was 116.1 mm(3) (range, 48.1 to 374.8 mm(3)) in phase A and 293.3 mm(3) (range, 109.4 to 1134.9 mm(3)) (P <.001) after 3 days of phase B; it returned to the phase A value after 4 days of phase C. The contraction index was 65.2% (range, 40.6% to 78.2%) in phase A and 1.7% (range, 0% to 8.4%) (P <.001) after 3 days of phase B. It returned to its phase A value immediately after bolus enteral feeds were resumed in phase C.

CONCLUSIONS

Continuous enteral feeding leads to an enlarged, noncontractile gallbladder in infants. Emptying is observed immediately after bolus feeds are resumed, and volume returns to baseline after 4 days. The mode of feeding has important bearings on the motility of the extrahepatic biliary tree.

Biliary sludge formation during enteral nutrition: prevalence and natural history

BACKGROUND

Total parenteral nutrition is an etiologic factor in the formation of biliary sludge. We studied whether enteral nutrition is also a risk factor for sludge.

METHODS

Fifty patients with a needle catheter jejunostomy (NCJ) placed during a major abdominal operation underwent preoperative and weekly postoperative ultrasonography until NCJ feedings were discontinued (1 to 6 weeks).

RESULTS

All patients were men. The mean age was 63.2 +/- 1.6 years. Fourteen asymptomatic patients (28.0%) had biliary sludge within 2 weeks of beginning enteral feedings through a NCJ. Complete ultrasonographic resolution of sludge was observed in 13 of the 14 positive patients within 1 to 2 weeks of resuming an oral diet. One patient was lost to follow-up after 14 week; a positive sonogram had persisted but the patient remained asymptomatic. During the period of observation, no other patient had signs of biliary tract disease.

CONCLUSIONS

(1) Biliary sludge may form in some patients during enteral feeding with NCJ. (2) Sludge is cleared by the gallbladder once an oral diet is resumed. (3) There appears to be little risk of complications during postoperative enteral feeding.

Prevalence of gallbladder sludge in dogs as assessed by ultrasonography

Ultrasonography of the gallbladder was performed in 3 groups of dogs: 30 clinically healthy dogs, 50 dogs with hepatobiliary disease, and 50 dogs with diseases other than hepatobiliary disease. The gallbladder was evaluated for the presence of sludge (echogenic material without acoustic shadowing). Maximal gallbladder length, width, height, and area were measured as well as the gallbladder wall thickness. The relative sludge area was calculated as the ratio of sludge area over gallbladder area on longitudinal images. No significant difference was found in the prevalence of gallbladder sludge among healthy dogs (53%), dogs with hepatobiliary diseases (62%), and dogs with other diseases (48%). The mean age of dogs with sludge was higher than the mean age of dogs without sludge in dogs with hepatobiliary disease and dogs with other diseases (p < 0.05). The mean relative sludge area did not differ significantly among the 3 groups. A trend to larger gallbladder dimensions in dogs with sludge compared to dogs without sludge was detected within the 3 groups. The gallbladder wall thickness was not different between dogs with and without sludge within the 3 groups. However, the gallbladder wall was more frequently isoechoic than hyperechoic to the liver in dogs with sludge than in dogs without sludge. The results of this study indicate that gallbladder sludge, in dogs, is not particularly associated with hepatobiliary disease and should be considered an incidental finding.

Changing indications for laparoscopic cholecystectomy. Stones without symptoms and symptoms without stones

In less than a decade, laparoscopic methods have dramatically improved the safety and convenience of cholecystectomy. As a result, the number of cholecystectomies performed nationwide has increased significantly. Whether this increase is a reflection of any major change in operative indications is unclear; the actual answer may vary from community to community. Silent gallstones continue to represent a sometimes contentious therapeutic dilemma. Because their natural history is unlikely to have changed, the management guidelines previously established for open cholecystectomy continue to have relevance today. Thus, it can be agreed that the majority of patients with silent gallstones do not require a cholecystectomy. The changing risk-benefit ratio suggests that some liberalization of these guidelines may now be in order. Already a number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients who are found to have gallstones during screening. Available evidence also appears to support the use of pre-emptive laparoscopic cholecystectomy for other indications such as in selected women of childbearing age, young children, and patients with very large gallstones. The problem of silent gallstones in diabetics continues to be more enigmatic, but some complicated diabetics are probably best managed with operation. Other patient groups who are at high risk of having adverse outcomes from expectant management will be more precisely identified by future research efforts. Laparoscopic cholecystectomy should also be helpful in patients with various forms of acalculous biliary disease. However, special caution is advisable in approaching chronic acalculous cholecystitis until more specific and reproducible diagnostic methods are further validated.