Results of early laparoscopic cholecystechtomy in patients with acute calculous cholecystitis and concomitant ischemic heart disease

Abstract

The aim — to evaluate the results of early laparoscopic cholecystectomy (LC) in patients with acute calculous cholecystitis (АСС) and concomitant ischemic heart disease.Materials and methods. The study included 107 patients with ACC: 56 (47.7 %) women and 51 (52.3 %) men aged 55 to 82 years old, on average 70.2 ± 0.6 years, treated at the surgical department. All patients were hospitalized within 29.9 ± 1.4 hours. Among all patients with angina pectoris 93 (86.9 %) had stable variant, 14 (13.1 %) — unstable, 6 (6.5 %) patients have had I class of stable angina pectoris, II class have had 45 (48.4 %), III class — 31 (33.3 %), IV class — 11 (11.8 %) of patients. According to NYHA classification, functional class of chronic heart failure (CH) had been diagnosed in 8 (7.5 %) patients, II class — in 59 (55.1 %), III class — in 33 (30.8 %), IV class — in 7 (6.5 %) of cases. 29 (27.1 %) patients have had atrial fibrillation, including permanent form in 19 (65.5 %), paroxysmal form — in 10 (34.5 %) of patients. ESV had been reported in 5 (4.7 %) patients. According to the classification of TG13, the severity of ACC variates: I grade in 37 (34.6 %) patients, II grade — in 41 (38.3 %), and grade III — in 29 (27.1 %) of patients. Anticoagulant and antiplatelet therapy before surgery was given to 95 (88.8 %) of patients. The frequency of catarrhal, phlegmonous and gangrenous forms of LC was 46 (43.0 %), 29 (27.1 %), 32 (29.9 %), respectively. In 47 (43.9 %) of patients there was a paracystic infiltrate, in 14 (13.1 %) — paravesical abscess, in 12 (11.2 %) — local peritonitis. LC (with the creation of carboxyperitoneum 12 — 15 mm Hg) is performed on average 41.1 ± 1.3 hours from the onset of the disease. The method of choice for anesthesia was total intravenous anesthesia (TIVA) with trachea intubation and artificial lung ventilation. The study points were cardiac events in the intraoperative and early postoperative periods.Results and discussion. ECG­signs of intraoperative myocardial ischemia appeared in 23 (21.5 %) patients with duration ranged from 10 up to 25 min, on average 14.8 ± 0.7 min, systolic blood pressure (SBP) < 70 mm Hg decreasing for 5 — 15 min (on average 7.7 ± 0.4 min) registered in 31 (29.0 %) patients; decreasing diastolic blood pressure < 50 mm Hg — in 12 (11.2 %) patients, lasting from 5 to 15 min, on average 8.1 ± 0.4 min. Episodes of reduced saturation level occured in 50 (46.3 %) patients. Bilateral bundle branch block occurred in 9 (8.4 %) patients and atrial fibrillation paroxysms occurred in 9 (8.4 %) patients. Elevated tissue bleeding was observed in 18 (16.8 %) of patients. Stepping up in the NYHA class in the postoperative period occurred in 13 (12.1 %) patients. In this case, the intensification of heart failure occurred in 9 patients from HF II to HF III, and in 4 patients from HF III to HF IV. The deepening of HF correlated with a hemoglobin decreasing < 100 g/L (r = 0.704), episodes of decreasing SBP < 70 mm Hg (R = 0.569), decreased saturation (< 90 %) (r = 0.547), ischemia during anesthesia (r = 0.363), duration of operation (r = 0.495), and negatively correlated with MET (r = –0.436). The ratio of chances for HF deepening in patients with destructive cholecystitis to non­destructive cholecystitis is 11.02 (95 % DM: 1.4 — 88.2). Myocardial infarction (MI) developed in 6 (5.6 %) patients (Q­infarction — in 2, and non Q­infarction — in 4). The occurrence of MI correlated significantly with the intensification of the heart failure (r = 0.438), hypercoagulation before surgery (r = 0.333) and a hemoglobin decreasing < 100 g/L during the operation (r = 0.311).Conclusions. In patients with ACC and concomitant IHD, myocardial ischemia was observed in 21.5 % of patients with early LC. Blood pressure lowering: systolic (< 70 mm Hg) in 29.0 %, diastolic (< 50 mm Hg). Besides that, 11.2 % of patients have had reduction of saturation level (< 90 %) in 46.3 %, new episodes of cardiac arrhythmia in 16.8 %, increased bleeding in 16.8 %. Intensification of HF and MI in the postoperative period occurs in 12.1 % and 5.6 % of patients, respectively. Complications for the cardiovascular system correlate with the form of ACC and its severity class (TG13), NYHA class, FC for angina pectoris, MET level, changes in the hemostatic system (hyper­ and hypocoagulation), and preliminary anticoagulant therapy.