159 Hellenic Journal of Surgery 2011; 83: 3
Symptomatic Cholecystolithiasis as a Rare Late Biliary Complication 16 Years After Orthotopic Liver Transplantation, Successfully Treated with Laparoscopic Cholecystectomy Case Report S. Vernadakis, G. C. Sotiropoulos, G. M. Kaiser, E. Christodoulou, S. Kykalos, B. Juntermanns, Z. Mathe, F. Weber, A. Paul, J. W. Treckmann Received 28/01/2011 Accepted 21/03/2011
Abstract
Liver transplantation, Cholecystolithiasis, Laparoscopy.
bladder of the donor that was in turn transplanted with the liver-graft. The reasoning was that it would allow procedures such as cholecystojejunostomy or donor gallbladder conduit for biliary tract reconstruction to be performed after post-transplant biliary complications [5, 12-14]. Although laparoscopic cholecystectomy is not contraindicated after upper abdominal surgery, it is associated with an increased need for adhesiolysis, a higher conversion rate to open surgery, prolonged operating time, an increased incidence of postoperative wound infections and a longer postoperative stay [14-19]. To the best of our knowledge, this is the first reported case in the world literature of a successful laparoscopic cholecystectomy after liver transplantation.
Introduction
Case Report
Orthotopic liver transplantation (LT) has established its role as the optimum treatment for endstage liver disease and selected cases of hepatocellular carcinoma. Although biliary stones and sludge are relatively common after LT, cholecystolithiasis has not yet been reported. We present the case of post-LT symptomatic cholecystolithiasis, which was successfully treated with laparoscopic cholecystectomy. The incidence of biliary complications after LT and the role of laparoscopy after prior upper abdominal operations are further discussed.
Key words:
Liver transplantation is the therapy of choice for many patients with end-stage liver disease, liver cancer, fulminant hepatic failure and metabolic liver diseases. Biliary complications are a common cause of morbidity following orthotopic liver transplantation (LT). Complications involving the biliary tree usually occur within the first 3 months after transplantation and can be observed in up to 34% of patients [1-6]. While bile leaks and biliary strictures are the most common biliary complications, others such as sphincter of Oddi dysfunction, biliary obstruction from stones, sludge or casts, haemobilia, and mucoceles have also been described [1, 2, 4-5, 7-9]. Cholecystolithiasis is a very rare late biliary complication following liver transplantation [10]. Commonly, the liver allograft is transplanted without the gallbladder. During the 1980s and early 1990s, few transplant centres preserved the gall-
G. C. Sotiropoulos (Corresponding author), S. Vernadakis, G. M. Kaiser, E. Christodoulou, S. Kykalos, B. Juntermanns, Z. Mathe, F. Weber, A. Paul, J. W. Treckmann Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany e-mail:
[email protected]
A 59-year-old woman was referred to our department for elective interval cholecystectomy due to symptomatic cholecystolithiasis. In March 1993, about 16 years earlier, the patient had undergone an ABO-compatible deceased LT for end-stage cirrhosis due to chronic hepatitis-B virus infection. The donor was a 37-year-old female with no history of cancer. The liver graft was transplanted with the gallbladder, which was free of calculus, with an excellent arterial perfusion after the reperfusion of the graft. An end-to-end choledocho-choledochostomy for biliary reconstruction was performed. The initial immunosuppressive regimen consisted of cyclosporine, azathioprine, and prednisone, according to our protocol at the time. Sixteen years after the transplantation, she was referred to our institution as she had experienced persistent abdominal discomfort and pain in the right upper quadrant several times in the past four to five weeks. Physical examination revealed tenderness on palpation of the right upper quadrant of the abdomen and of the epigastrium. Laboratory tests, including a liver biochemical profile, were within normal range. Ultrasonography demonstrated numerous gallstones within the gallbladder without any signs of acute cholecystitis or dilatation of the intra- and extrahepatic biliary tree. Immunosuppression at this time included only cy-
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160 Symptomatic Cholecystolithiasis as a Rare Late Biliary Complication 16 Years After Ortho topic Liver Transplantation, Successfully Treated with Laparoscopic Cholecystectomy
closporine, at a dosage of 30 mg twice a day (trough level of 80 ng/ml). A laparoscopic cholecystectomy was performed using the four-trocar technique in French position. The creation of pneumoperitoneum was achieved by the open (Hasson) technique. The operation was uneventful and was completed in 50 minutes; (Fig. 1, 2) no drainage was placed in the gallbladder fossa. Immunosuppression with cyclosporine alone, at the same dosage of 30 mg twice a day, was continued postoperatively (aimed trough levels 75–125 ng/ml). The patient was discharged home on the 4th postoperative-day.
Discussion Since the first LT was performed in humans in 1963, enormous progress has been made in terms of surgical techniques, improvements in immunosuppressive regimens and graft preservation. The role of LT has been established as the optimum treatment for end-stage liver disease and selected cases of hepatocellular carcinoma, achieving 1-year survival rates of 90% and 10-year predicted survival of 70% [3-4]. Despite the surgical advances and improvement in survival rates, complications involving the biliary tree remain a common problem after LT. Associated with significant morbidity and mortality (2% - 7%) [3-4, 20] and re-transplantation rates of 6%12.5% [4, 21], they still constitute one of the leading causes of graft dysfunction or loss in recipients. Reported rates of biliary complications range from 6% to 34% of transplants, depending on the type of graft, donor and biliary anastomosis performed [1-6]. Early complications occur within a few weeks after transplantation and are mainly represented by bile leakage. Late complications, which become evident from 3 months to a few years later, include strictures, intraductal stones, biliary casts or sludge formation, kinking, dysfunction of the sphincter of Oddi and mucocele formation [3-4, 20]. The spectrum of biliary complications has changed over the past decade because of the establishment of split liver, reduced-size and living donor liver transplantation. The choice of biliary anastomosis is a major determinant in the subsequent risk of biliary complications after LT. In some institutions, especially at the beginning of the liver transplant era until the early 1990s, the reason the donor gallbladder was preserved was to allow its use in surgical management in the event of biliary complications after LT. Biliary tract reconstruction was performed in some transplant centres using the interposition of the donor gallbladder as a conduit between the donor bile duct and the recipient bile duct or a jejunal loop
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[11-12, 20-21]. The gallbladder of the donor liver is no longer preserved and procedures such as cholecysto-jejunostomy or gallbladder conduit have been largely abandoned. Current practice in most institutions is to use the choledocho-choledochostomy and Roux-en-Y hepaticojejunostomy [2-4, 6, 23-24]. The most common bile duct filling defects are caused by gallstones. Other causes include sludge, blood clots, casts and migrated stents. Biliary stones and sludge are relatively common after LT, with an incidence of 3%-12% [1, 4, 24]. Factors related to the formation of intraductal stones and sludge are the presence of strictures, bacterial infection and obstruction. Cholecystolithiasis has only rarely been reported as a late biliary complication after LT [10]. The present case is the first reported case in the literature of a successful laparoscopic cholecystectomy in a patient with symptomatic cholecystolithiasis 16 years after LT.
Conflict of interest The authors declare that they have no conflict of interest.
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