Secondary sclerosing cholangitis in cardiac surgical patients: A complication with a dismal prognosis

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 154; no. 3; pp. 906 - 912
• Main Authors: Schade, Ina, MD, Radakovic, Dejan, MD, Hoffmann, Jörg, MD, Sommer, Sebastian-Patrick, MD, PhD, Stefenelli, Ullrich, MPH, Schimmer, Christoph, MD, PhD, Leyh, Rainer G., MD, PhD, Aleksic, Ivan, MD, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.09.2017
• Subjects: Aged; Alkaline Phosphatase - blood; Bilirubin - blood; cardiac surgery; Cardiothoracic Surgery; Cardiotonic Agents - therapeutic use; Cardiovascular Surgical Procedures; Case-Control Studies; Cholangitis, Sclerosing - drug therapy; Cholangitis, Sclerosing - mortality; Critical Illness; extracorporeal circulation; Female; gamma-Glutamyltransferase - blood; Germany - epidemiology; Humans; intensive care medicine; Intubation, Intratracheal - statistics & numerical data; Liver Transplantation - statistics & numerical data; Male; Middle Aged; Postoperative Complications - mortality; Reoperation - statistics & numerical data; Respiration, Artificial - statistics & numerical data; Retrospective Studies; secondary sclerosing cholangitis; Time Factors; Vasoconstrictor Agents - therapeutic use; Germany; ECMO; intra-aortic balloon pump; aortic valve replacement; IABP; extracorporeal circulation; ALP; secondary sclerosing cholangitis; gastroenterology; endoscopic retrograde cholangiopancreatography; intensive care medicine; GGT; cardiac surgery; gamma glutamyl transpeptidase; alkaline phosphatase; extracorporeal membrane oxygenation; ERCP; CABG; AVR; GE; coronary artery bypass grafting
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2017.04.041

Abstract Objectives Secondary sclerosing cholangitis in critically ill patients is a rapidly progressing disease leading to biliary fibrosis and cirrhosis. We describe the course of sclerosing cholangitis in critically ill patients after cardiac surgery and compare this with matched patients. Methods A retrospective search for “secondary sclerosing cholangitis” and “liver and/or hepatic failure” in all adult patients (aged 18-93 years) who underwent cardiac surgery from April 2007 to March 2016 identified 192 of 8625 patients. Of those, 12 were diagnosed with sclerosing cholangitis in critically ill patients (incidence, 0.14%). A 3:1 matching was performed. Laboratory values, pharmacologic requirements, ventilation times, mechanical circulatory support, and endoscopic retrograde cholangiopancreatography studies were extracted from the hospital database. Results A total of 9 men and 3 women were affected (age 71 years; range, 59.8-75.5 years). Critically ill patients with sclerosing cholangitis required vasoconstrictors and inotropes longer than control patients (norepinephrine 356.5 hours [264.5-621] vs 68 hours [15-132.5], P  = .003; enoximone 177 hours [124.3-249.5] vs 48.5 hours [12-81 hours], P  < .001, respectively). Critically ill patients with sclerosing cholangitis had longer intubation time (628.5 hours [377.3-883] vs 25 hours [9.8-117.5]; P  < .001) and more surgical revisions (3 [2.5-6] vs 1 [0-2], P  = .003) than the matching group. Bilirubin (23.3 mg/dL [14.4-32.9] vs 1 mg/dL [0.6-2.7]; P  < .001), gamma-glutamyltransferase (1082.3 U/L [259.5-2265.7] vs 53.8 U/L [35.1-146]; P  < .001), and alkaline phosphatase (751.5 U/L [372-1722.3] vs 80.5 U/L [53.3-122]; P  < .001) were higher in critically ill patients with sclerosing cholangitis. One critically ill patient with sclerosing cholangitis underwent successful liver transplantation. A total of 11 patients sclerosing cholangitis died (92%) versus 12 patients (33%, P  < .001) in the control group. Conclusions Sclerosing cholangitis in critically ill patients is a fatal complication in patients undergoing cardiac surgery who have a complicated postoperative course with prolonged vasoconstrictor, inotropic, and respiratory therapy, or who require frequent surgical revisions. Liver transplantation remains the only curative option but is often precluded by the age and critical state of patients undergoing cardiac surgery.