Transplantologiya - 2016. - № 1. - P. 25-28.
Acute complicated calculous cholecystitis
after bilateral lung transplantation
A.M. Kuz'min, S.G. Gyulasaryan
N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow
Healthcare Department, Moscow, Russia
M.Sh. Khubutiya, M.L. Rogal', E.A. Tarabrin, A.N. Smolyar,
Contact: Aleksey M. Kuz'min,
The paper describes a case of successful treatment of acute
destructive calculous cholecystitis after bilateral lung transplantation.
Keywords: acute calculous cholecystitis, lung transplantation,
Lung transplantation is the only option to treat the end-stage chronic
obstructive pulmonary disease (including bronchiectasis), idiopathic
pulmonary fibrosis, cystic fibrosis, and pulmonary hypertension. An
increased bile lithogenicity in combination with drug immunosuppression
therapy after transplantation raise the risk of biliary complications .
Abdominal surgical complications occur in 28% of patients after heart
transplantation or combined heart-lung transplantation , and in 10% after
immunosuppressive, anti-bacterial, and anti-viral therapies are characterized
by atypical course with "vague" clinical pattern and severe complications
. Most investigators  believe that preventive cleansing of biliary tree is
not indicated in the patients on the waiting list for kidney transplantation or
those after transplantation. There is no standardized tactics for cholelithiasis
treatment in patients with the end-stage heart disease, and those after heart
transplant. Three mutually exclusive points of view still exist: to perform a
planned laparoscopic cholecystectomy before heart transplantation , after
it , or at the onset of clinical symptoms of cholelithiasis complications,
including such as hepatic colic, acute cholecystitis, and biliary pancreatitis
. Elective cholecystectomy is well tolerated by the patients after heart
transplantation , the laparoscopic approach being the preferred one .
There are only few reports in literature on the treatment of cholelithiasis and
its complications after lung transplantation [1, 3, 10]. Therefore, we believe
it appropriate to present a clinical case report from our experience.
Patient T., 44 years old (medical record #2376814), was referred to
the N.V.Sklifosovsky Institute for Emergency Medicine on 18.09.2014 with
complaints on an occasionally occurring moderate epigastric pain, the body
temperature elevation up to 38° C once in 3 days.
From the previous history we revealed that on December 5, 2013, the
patient underwent bilateral lung transplantation for severe bronchiectasis
lung disease with chronic respiratory failure, the transplantation was
performed in the N.V.Sklifosovsky Institute for Emergency Medicine. The
postoperative period was without major complications, and on the 18
after surgery, the patient was discharged home to be followed-up by a
pulmonologist at the local clinic on residence. Gallstone disease and
cholecystolithiasis had been first diagnosed by ultrasonography several years
before lung transplantation. There were no clinical symptoms of gallstone
After lung transplantation, the patient was on immunosuppressive
therapy (Prograf, 3 mg/day; methylprednisolone, 16 mg/day; mycophenolate
mofetil, 2000 mg/day), received antibacterial, antiviral and antifungal drugs
(azithromycin, 750 mg/week; co-trimoxazole, 960 mg/day; valganciclovir,
900 mg/day; voriconazole, 400 mg/day).
In July 2014, the patient reported an episode of moderate pain in the
epigastric area that was controlled by a single dose of No-Spa. There was no
nausea, vomiting, or fever. In August 2014, the pain attack repeated, the
patient had occasional rises in the body temperature up to 38° C (once every
3 days). The patient was evaluated at an out-patient setting, the physical
esophagogastroduodenoscopy. The surgeon's and gastroenterologist's
examination did not reveal any acute abdominal surgical diseases. It should
be emphasized that hematology and biochemistry blood tests gave normal
results with one exception (hemoglobin 96 g/L) suggesting moderate
On September 9, the patient was hospitalized with persisting fever to a
local public hospital for further observation. Ultrasonography revealed the
signs of acute phlegmonous calculous cholecystitis, and perivesical abscess.
On September 18, 2014, the patient was transferred to the Department of
Urgent Hepato-Biliary Surgery of the N.V.Sklifosovsky Institute.
The patient was examined on admission. Ultrasonography revealed
the signs of infiltration in the right subhepatic space involving
mesogastrium, acute calculous gangrenous-perforating cholecystitis,
perivesical abscess. On the day of admission the patient underwent a
percutaneous transhepatic microcholecystostomy and a percutaneous
transhepatic drainage of the perivesical abscess under ultrasonographic
guidance using a single-staged method with Pigtail 9Fr drainage system; the
procedures being performed under local anesthesia. The drainage system
evacuated 50 ml of purulent discharge from the gallbladder, and 100 ml of
similar purulent discharge from the abscess cavity; the microbiology study
of pus showed Klebsiella pneumonia
with a titer of 10
, sensitive to
Fistulography (see Fig.) demonstrated the signs of a gall bladder
internal fistula with communication to the right curvature of the colon
through the abscess cavity, calculous cholecystitis, timely entering of the
contrast agent to the duodenum, no evidence of choledocholithiasis.
A – Gall bladder;
B – Perivesical abscess
The abscess drain was replaced by a larger-bore tube (30 Fr) in a step-
wise fashion, the antibiotic therapy was continued (imipenem, 1000
mg/day), as were the detoxification therapy, the fractional lavage of the
abscess cavity and the gall bladder.
The patient's condition improved, the pyo-intoxication symptoms were
controlled, however, that did not result in the abscess cavity reduction, nor in
the fistula cure. The patient's perivesical infiltrate also persisted involving a
hepatic flexure of the colon that made the differentiation of organ walls
hardly possible. The case was discussed at the concilium of specialists that
made the following decisions: 1. To operate the patient using the laparotomy
approach. 2. To make the resection outside the infiltrative focus in order to
avoid the dissemination of the purulent process. According to the decision
taken at the concilium, on October 22, 2014, the patient was operated on.
Using endotracheal anesthesia, we performed laparotomy, cholecystectomy,
and right hemicolectomy with "end-to-side" ileotransverse colon
anastomosis. Samples of the colon, the small intestine, and the gall bladder
were sent to histological examination that gave the following results: "the
wall of the gallbladder having multiple sclerosis across all layers, edema,
diffused and focal lymphocyte infiltration with a moderate admixture of
plasma cells, macrophages, and few granulocytes outside the abscess, the
sclerosis and inflammatory infiltration in the adjacent area being more
pronounced; the infiltration contains large numbers of granulocytes. The
walls of both abscesses contain fibrous tissue, the lumen is laid with
amorphous acellular masses, pyo-necrotic detritus; there is the colonization
of the fungus mycelium. Inflammation affects the wall of the colon from
outside; the small and large intestine, and the appendix wall outside the
abscess wall are without inflammatory abnormalities. Findings in the
external intestinal wall in the fistula area are typical of the abscess wall
pattern; the mucosal damage is secondary, of short-term standing. There is
chronic calculous cholecystitis in exacerbation. Pericystic and intercellular
abscesses contain fungus mycelium colonization, drained into the colonic
lumen". After surgery, the patient continued antimicrobial (Meronem, 3
g/day) and immunosuppressive therapy. The early postoperative period was
At day 7 after surgery, the patient developed the signs of systemic
inflammatory response with fever up to 39° C, leukocytosis 14x10
the shift to myelocytes (7%) in the white blood cell differential count. At
examination, no findings of intra-abdominal pyo-septic inflammation were
seen. A superficial suppuration of the laparotomy wound was found. The
skin sutures were removed and the topical treatment was initiated.
Microbiological study of wound discharge revealed Klebsiella pneumonia.
The wound gradually cleared itself; "sluggish" granulations appeared.
However, the patient's hyperthermia still persisted. Ultrasonography
revealed localized fluid collections in the anterior abdominal wall and both
gluteal areas. At day 20 after surgery, the abscesses of the anterior
abdominal wall, and both gluteal areas were incised and evacuated yielding
30, 80, and 60 ml of thick yellow-greenish pus, respectively. Microbiology
study of the abscess contents detected Klebsiella pneumonia. No flora
growth was found in blood cultures. A systemic antibiotic therapy with
sulperason (4 g/day) was initiated to control the dissemination of purulent
process. The topical therapy was continued. The intoxication was gradually
controlled, purulent cavities cleared themselves and healed by secondary
Further postoperative course was complicated by a right lower lobe
pleuropneumonia. The antibacterial therapy was supplemented with
meropenem (2 g/day), tigacil (100 mg/day); the patient received the course
of antifungal therapy with Vfend (400 mg/day), and inhalations with
colistin, and amphotericin B. The microbiology of sputum and bronchial
washings showed no abnormal flora.
The patient was discharged from hospital in a satisfactory condition
for outpatient follow-up care on the 92
day from hospital admission.
Due to a mandatory immunosuppressive therapy, the patient had a
non-typical course of acute calculous cholecystitis. Mild to moderate pain
and occasional rises in the body temperature hampered a timely diagnosis of
gallstone disease complications. Immunosuppression led to multiple
infection complications with the pathogen non-typical for abdominal
surgery, and all those delayed the healing process. The authors believe that
the described clinical case report serves an evidence in favour of planned
cleansing measures for chronic surgical diseases in patients undergoing lung
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