MANAGEMENT OF BILIARY COMPLICATIONS AFTER HEART-TRANSPLANTATION

Background: Immunosuppression increases the risk of biliary complicati ons in heart transplant recipients. Methods: Patients undergoing heart transplantation since 1985 who were at risk for cholelithiasis (n = 6 0) were retrospectively studied. Results: Cholestatic jaundice develop ed in all patients after the operation because of biliary obstruction from cholelithiasis, cyclosporine toxicity, Imuran toxicity, or Gilber t's disease. The incidence of cholelithiasis or sludge was 42% (n = 25 of 60). Gallstones developed within 1.8 +/- 1.1 years in 17% of patie nts (n = 8 of 48) with a normal pretransplantation ultrasonogram. Bili ary colic or gallstone pancreatitis developed 2 +/- 1.2 years after tr ansplantation in 58% of patients (n = 7 of 12) with asymptomatic galls tones diagnosed before transplantation. The overall incidence of chole cystectomy or cholecystectomy with Roux-en-Y cystojejunostomy was 40% (n = 24). Both open cholecystectomy (n = 5) and laparoscopic cholecyst ectomy (n = 19) were performed without significant complications. Reco very is significantly more rapid (p < 0.05) after laparoscopic cholecy stectomy versus open cholecystectomy (1 week versus 3 weeks). Conclusi ons: This analysis indicates that transplant candidates who have galls tones on pretransplantation evaluation or in whom gallstones develop a fter transplantation should undergo laparoscopic cholecystectomy at th e earliest time in their posttransplantation course (i.e., 3 months) r egardless of their symptomatic status. Removal of the diseased gallbla dder not only simplifies the evaluation of cholestatic jaundice by eli minating the need for multiple ultrasonograms to exclude acute cholecy stitis or choledocholithiasis but also safely minimizes the risk of th e development of severe biliary complications.