Acute acalculous cholecystitis following open heart surgery.

We undertook a retrospective study designed to ascertain the frequency of acute acalculous cholecystitis (AAC) following open heart surgery. In the study period 1982-1990, 22 of 6393 patients following open heart surgery were recognized to have developed AAC, an incidence of 0.34%. The majority of patients (16/22) presented within the first postoperative week. Vague right upper quadrant physical findings, nonspecific changes in the liver function chemistries and unexplained sepsis frequently led to radiologic evaluations. Ultrasonography was the most valuable radiologic study, with a diagnosis sensitivity of 82%. Technetium cholescintography can serve as a useful adjunct when interpreted in the context of other clinical findings. Cholecystectomy was performed in 20 patients and cholecystostomy in two. Nine (41%) patients had gangrenous gallbladders with frank perforation in two. A specific preoperative diagnosis was made in 19 patients (86%). Fifteen patients survived for a mortality rate of 32%. In 12 of 15 survivors (80%), the diagnosis of AAC was established and laparotomy performed within 48 hours of first clinical suspicion. Gangrene and perforation were seen in 87% of patients in whom surgery was delayed. AAC is a life-threatening condition especially in critically ill patients. Experience suggests that early diagnosis and operative intervention are the key elements of treatment. Delay of operative management on the grounds of recent cardiac surgery is not justified.

Disc embolization of Björk-Shiley mitral prosthesis without strut fracture.

Strut fracture with subsequent embolization of the Björk-Shiley mitral prosthesis is a rare but recognized complication. A case of disc embolization without strut fracture was managed successfully by early surgical intervention. The preoperative chest x-ray film demonstrating apparently intact major and minor struts underscores the importance of a high index of suspicion to make an early diagnosis.