ABSTRACT
Biliary disease in conjunction with heart transplantation was encountered in 13 of 33 patients: in the past history (three patients), at pretransplant evaluation (nine patients), and appearing de novo after transplantation (one patient). Four patients with asymptomatic cholelithiasis underwent transplantation: biliary complications requiring emergency and/or urgent surgery occurred in all, with two deaths. Potentially complicating factors included (1) untoward effects of steroids on tissue healing and infection and (2) interaction between liver dysfunction and/or external bile loss and cyclosporine metabolism. Therapeutic lessons learned from this experience involve (1) selection of monoclonal antibodies over methylprednisolone for rejection control, (2) return of drained bile to the gastrointestinal tract, and (3) careful cyclosporine level and dosage monitoring. Five candidates with asymptomatic cholelithiasis underwent elective pretransplant biliary surgery; despite their compromised heart function, all patients had an uncomplicated postoperative course. We conclude that asymptomatic biliary disease is frequent in transplant candidates, can lead to serious morbidity and/or mortality after transplantation, and ideally can and should be treated before transplantation.
Subject(s)
Biliary Tract Diseases/complications , Heart Transplantation , Adult , Antibodies, Monoclonal/therapeutic use , Bile/physiology , Biliary Tract Diseases/physiopathology , Biliary Tract Diseases/surgery , Cyclosporins/administration & dosage , Cyclosporins/adverse effects , Cyclosporins/therapeutic use , Drainage , Female , Graft Rejection , Heart Diseases/surgery , Humans , Liver/physiopathology , Male , Methylprednisolone/adverse effects , Methylprednisolone/therapeutic use , Middle AgedABSTRACT
With perforation during acute diverticulitis, with or without abscess, the highest mortality occurs in patients in whom a transverse colostomy with drainage alone is done. This is no longer to be considered an acceptable method of management. The advantage of removal of the diseased intestine is paramount. Anastomosis under unfavorable conditions is avoided. The results in this group of severe, acutely ill patients with associated multiple systemic disease encouraged wider application of the Hartmann operation for the complex problems of inflammation of the diverticulum.
Subject(s)
Diverticulitis, Colonic/surgery , Intestinal Perforation/surgery , Abscess/surgery , Acute Disease , Aged , Cardiovascular Diseases/complications , Diabetes Complications , Diverticulitis, Colonic/complications , Humans , Intestinal Perforation/etiology , Lung Diseases/complications , MethodsABSTRACT
We present our experience in a series of 25 cases involving reconstruction of bowel continuity after the Hartmann operation for perforated diverticulitis. The term "colostomy closure" has been judiciously avoided because in no way are these procedures comparable. Careful timing and restraint are encouraged to allow adequate recovery from the initial disease process and resultant surgery. Some technical aids are mentioned which may assist in limiting morbidity and mortality.
