Multidisciplinary approach to acute cholecystitis in a severely cardiopathic patient. Case report and review of literature


 Background. Acute cholecystitis in severely cardiopathic patient after major cardiac surgery represent a challenge for surgeons. Treatment with cholecystostomy could represent a chance for patients even if there are many topics of greatest debate about it: the technique of performing it (if transhepatic or transpapillary), the timing of optimal duration, the timing of drain removal, the need of further examinations before the removal as well as the timing for definitive surgery. We therefore deemed important to share our experience in the treatment of acute cholecystitis in a severe cardiopathic patient, while attempting to clarify all the major topics related to the management of percutaneous cholecystostomy through a literary review.Case presentation. A 58-year-old severly cardiopathic patient who had undergone surgery for hip replacement, developed an acute calcolous cholecystitis a few days after surgery to resolve which a percutaneous cholecystostomy was the chosen strategy. Two weeks after discharge, a cholangiography through the cholecystostomy and a MRI cholangiopancreatography revealed the presence of stones in the cystic duct and in the ductus choledochus. The definitive treatment was decided after consulting with a multidisciplinary team. An open cholecystectomy with simultaneous removal of the cholecystostomy, endoscopic removal of stones and sphincterotomy of the Oddi papilla was performed. The patient is currently healthy and his heart function is satisfactory. Conclusion. Although early cholecystectomy is the recommended choice for acute cholecystitis, a critically ill patients may benefit from a bridging therapy before definitive surgery. The multidisciplinary approach provided a safer solution for this frail patient.

replacement, developed an acute calcolous cholecystitis a few days after surgery to resolve which a percutaneous cholecystostomy was the chosen strategy. Two weeks after discharge, a cholangiography through the cholecystostomy and a MRI cholangiopancreatography revealed the presence of stones in the cystic duct and in the ductus choledochus.
The de nitive treatment was decided after consulting with a multidisciplinary team. An open cholecystectomy with simultaneous removal of the cholecystostomy, endoscopic removal of stones and sphincterotomy of the Oddi papilla was performed. The patient is currently healthy and his heart function is satisfactory.
Conclusion. Although early cholecystectomy is the recommended choice for acute cholecystitis, a critically ill patients may bene t from a bridging therapy before de nitive surgery. The multidisciplinary approach provided a safer solution for this frail patient.

Background
In case of patients not t for surgery (due to co-morbidities, as elderly patients) the Tokyo Guidelines (TG) 2018 (2) recommend the use of percutaneous cholecystostomy both in grade II and III of cholecystitis because this allow to convert a septic cholecystitis into a non-septic condition obtaining a reduction of the in ammation and improvement of the clinical condition (3). It is important to consider that WSES 2017 guidelines reported lack of high level evidence (LoE 4, GoR C) about this topic (1) and even if several case series, retrospective and observational studies exist (3) as well as a systematic review of the literature, the selection criteria, the results and even the conclusions reached by various authors are largely non-homogeneous (4).
The main controversial issues regarding cholecystostomy are the following: the different techniques used to perform it (whether transhepatic or transpapillary), optimal duration and removal time, indications for further examinations prior to removal and nally, the optimal timing of de nitive surgery.
In this paper, we report the case of a patient presenting with acute calculous cholecystitis following recent hip replacement who had undergone several cardiac surgical procedures for a myocardial infarction with interventricular septal rupture 18 months earlier. We deemed important to share our experience in the treatment of acute cholecystitis in a severe cardiopathic patient, while clarifying all the major issues related to the management of percutaneous cholecystostomy through a literary review.

Case Report
A 58 year-old man with cardiopathy presented with calcolous cholecystitis during the postoperative course following the prosthetic replacement of the femoral head under spinal anesthesia performed in June 2019. The calculous cholecystitis was con rmed by ultrasound examination and CTscan that showed a uid collection around the gallbladder with delaminated walls and the presence of stones inside of it. Leucocytosis and abdominal pain were also present. The home therapy included : oral assumption of aspirin, bisoprolol, furosemide, ivabradine, metolazone, potassium canreonate since, about 18 months earlier, the patient had undergone emergency cardiac surgery for an acute postmyocardial infarction rupture in the posterior portion of the interventricular septum (IVSR). For the surgical repair, a bovine pericardial patch was used ("infarction exclusion technique") through the left ventricular posterior wall and a concomitant coronary artery bypass graft (CABG) with the left internal mammary artery was anastomosed sequentially to the left anterior descending artery and the rst diagonal branch.
The postoperative cardiac ecocolordoppler showed a signi cant post-operative residual left-to-right shunt and therefore a new elective treatment was planned. A month after surgery, a percutaneuos attempt was carried out (with Amplatzer VSD Muscular Occluder n. 18 mm) to close the residual IVSR that was however unsuccessful, and a redo surgery was needed. In this instance, the septum was repaired through the tricuspid valve. A concomitant new onset of signi cant mitro-tricuspidal regurgitation also required both a mitral valve annuloplasty (with St Jude ring n. 26 mm) and tricuspid valve annuloplasty (by the Kay-technique). Finally, in order to improve postoperative hemodynamic status, the implantation of an Intra Aortic Balloon Pump (IABP) was necessary.
The postoperative course was uneventful except for the onset of a marked bradycardia that required pacemaker implantation.
At hospital discharge, the patient was symptomless and in a good and stable hemodynamic status. The cardiac ultrasound examination showed a residual mild left-to-right shunt, a moderate right ventricular dysfunction and a left ventricular ejection fraction of 35%. Follow-up outpatient checkups con rmed the stability of the patient's hemodynamic and clinical status.
At the time of acute cholecystitis, due to the patient high risk for cardiac condition, a bridging procedure with placement of a percutaneous cholecystostomy (PC) was the chosen strategy. PC was performed transhepatically under local anesthesia by our Interventional Radiologists team. Two weeks after discharge, a cholangiography through the cholecystostomy revealed the presence of stones in the cystic duct and in the ductus choledochus, con rmed by MRI cholangiopancreatography.
The de nitive treatment was decided after consulting with a multidisciplinary team composed of cardiac surgeons, cardiologists, anesthesiologists, and endoscopists. An open cholecystectomy with simultaneous removal of the cholecystostomy, endoscopic removal of stones and sphincterotomy of the Oddi papilla was performed. His cardiac conditions were checked again before surgery, revealing 31% ejection fraction (EF), slight pulmonary hypertension, minimal tricuspid valve insu ciency. Intraoperative phase was managed with advanced hemodynamic and anesthesia monitoring including a pulse contour method for cardiac output measurement (MostCare UP , Vygon, Caen, France), trans-esophageal echocardiography, and depth of anesthesia monitoring (Sedline ® , Masimo, Irvine, CA, USA).
After surgery he was transferred to the general ICU and then to the cardiac surgery unit from which he was discharged in satisfactory health condition on the tenth postoperative day. He is presently healthy and in good shape.

Discussion And Conclusion
Transhepatic percutaneous cholecystostomy is the recommended technique according to the TG2018(2). However, a recent systematic review about other techniques as EUS-guided gallbladder drainage and endoscopic transpapillary gallbladder drainage in the treatment of high-risk surgical patients with acute cholecystitis shows better results (7).
As reported in a paper by Hasbahceci et al (8), also the optimal duration of PC drainage is still a controversial issue. The suggested time is three to six weeks with an average of one month (8) but Morse et al. recommended that the PC tube should remain in place in critically ill patients until cholecystectomy.
(Table1) Also Wang et al, in another paper, suggested keeping the PC tube in place until cholecystectomy in critically ill patients. However, some other studies report adverse events, one of them (9) indicating that a drainage duration longer than two weeks may be associated with increased recurrence. Other policies have been catheter removal after con rmation of the patency of the cystic duct (8) or until surgery (10,11,12). Discharge with the PC tube in place until cholecystectomy, although a rare condition, is also reported in the literature (10).So far no de nitive conclusion has been drawn on the timing, although catheter removal can generally be performed after temporary clamping (13). Some Authors left the PC tube in place as a bridge procedure and performed early surgery after a mean of 9.68 ± 6.45 days (12).
However, further studies are needed to clarify the timing of PC tube removal, before de nitive surgery. Furthermore, recurrence after catheter removal is an important issue in patients not undergoing surgical treatment (10 ,12, 9). However the rate of recurrent gallstone related symptoms after drainage could have been lower if all the patients had undergone elective cholecystectomy. The CHOCOLATE study didn't explore this possibility because one of the advantages of percutaneous catheter drainage is surgical complication avoidance. For this reason, several Authors suggest that percutaneous cholecystotomy should be the SOLE procedure for high risk patients without any de nitive elective cholecystectomy (15,(17)(18)(19)(20). However, to the best of our knowledge, no studies are presently available on clinical, biochemical, or radiological predictors for failure of percutaneous catheter drainage in acute cholecystitis.
As to the high risk assessment of individual patients some Authors (4) report that in patients with an ASA score grade III and IV, PC is a minimally invasive treatment with a low complication rate for patients with ACC. In particular, in a retrospective study Aroori et al. (4) examined 53 patients who had undergone PC. Patients t enough for surgery had the PC removed at the time of surgery and a de nitive cholecystectomy was performed after 6 weeks. Despite the fact that based on the risk assessment over 50% of the patients were ASA IV and V, the majority survived and underwent the PC procedure. The associated presence of common bile duct stone (Choledocholithiasis) at presentation, has been reported to occur in 10% to 20 % in case series of cholelithiasis, with alower incidence during ACC ranging from 5 to 15 % of the patients (16) Intraoperative cholangiography is an invasive procedure with potential severe complications. Positive ndings on intraoperative cholangiography lead to intraoperative management of CBDS with prolonged operative time. In this case we utilized ERCP plus sphincterotomy as a combination of intraoperative procedure with the rendezvous technique [1,11,25]. Its morbidity includes pancreatitis, cholangitis, haemorrhage, duodenal perforation or allergy to contrast. However, while intraoperative cholangiography signi cantly increases the length of surgery [1], intraoperative ERCP plus sphincterotomy reduce risks for post-ERCP pancreatitis, as reported in the WSES guidelines 2016. Both require a dedicated staff in the operating room.
This case presented the following critical points: a) the patient's heart conditions with reduced EF and persistent ventricular septal defect due to previous myocardial infarction with ventricular septal rupture that required numerous surgical repairs and pacemaker placement; b) the need for an anesthesiological evaluation; c) the choice of PC for rst line treatment as a bridge procedure to manage the acute situation before de nitive treatment; In this case, the patient had a reduced functional reserve due to previous myocardial infarction with a ventricular septal defect that had required complex procedures. A bridging procedure was the best option for this, at the time, only 58 years old patient, therefore not tting into the common de nition of frailty associated with an age of over 60, but considered frail because of his cardiological conditions. According to the 2016 WSES guidelines, patients with ACC aged 80 years and over have worse clinical outcomes, morbidity and mortality rates (LoE 3 GoR B).
Although in the "2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population", the latter are also good candidates for early cholecystectomy, in 2016 Jocar et al (26) published a validation study for an emergency-general surgery-speci c frailty index, which demonstrated that chronological age was not an independent factor among the 15 variables included in the multivariate analysis for predicting postoperative complications, opening up the way to other possible surgical strategies.
2017 WSES guidelines reported several studies that identi ed old age as a perioperative risk factor for cholecystectomy, but with regard to early laparoscopic cholecystectomy it was unclear whether this would be the best treatment in the elderly population. The guidelines also reported a few retrospective cohort studies that compared the outcome of early versus delayed cholecystectomy in aged ACC patients but that had however failed to demonstrate a signi cant difference in mortality and postoperative complications [27][28][29][30].
Other studies consider cholecystostomy as a de nitive treatment without delayed cholecystectomy in an elderly population. Lack of a de nitive surgical treatment upon admission is associated with 38 % gallstone-related readmission rate in two years, compared to 4.4 % with early cholecystectomy [1,30].
In our case, the surgeon on call decided for a temporizing solution to solve the acute condition before de nitive surgery. This choice is supported by several studies suggesting that PC followed by late laparoscopic cholecystectomy is a suitable management for patients with ACC deemed un t for emergency surgery (9,31,32). In a paper of 2016, Popowicz et al, (32) reviewed the medical reports of seven hospitals with 799 pts. admitted in 2003, and 850 in 2008. Multivariate regression analysis was performed with adjustments for age, gender, degree of cholecystitis and Charlson comorbidity index (33). Notably, although patients treated with cholecystectomy as a bridge to elective surgery, were older with a predominance of females, the complications reported in the "bridge to surgery" group were entirely con ned to the subsequent nal gallbladder operation, con rming the Authors' conclusion that PC is a safe option in high risk patients with ACC. The only negative nding was the longer hospital stay in the PC group.
In our case, the choice of a step by step procedure with PC as bridging therapy before de nitive cholecystectomy, supported by a multidisciplinary cooperation among various medical and surgical specialties has proven to be a valuable strategy in providing the best treatment option for this frail, high risk patient.