Acute cholecystitis is a common complication after allogeneic stem cell transplantation and is associated with the use of total parenteral nutrition

Cholecystectomy in patients with hematologic malignancies

BACKGROUND

Cholecystectomy in patients with hematologic malignancies remains poorly understood.

METHODS

We retrospectively evaluated patients with hematologic malignancies who underwent cholecystectomy at a single institution.

RESULTS

Of 313 patients who presented for evaluation of abdominal pain, 64 underwent cholecystectomy for acute cholecystitis (34.4%), gangrenous cholecystitis (21.9%), chronic cholecystitis (23.4%), and cholelithiasis (20%). Most had a history of hematopoietic cell transplantation (62.5%) and/or immunosuppressive medication within 30 days of consultation (82.8%). Ultrasound had a 39% false-negative rate for acute nongangrenous cholecystitis. Operative time was 92 ± 39 min, 7 were performed open, 10 had intraoperative transfusions, and 4 had grade 3+ complications. Intraoperative transfusion was associated with increased postoperative length of stay (p = 0.03). Open procedure, operative time, estimated blood loss, intraoperative transfusion, and complications were not associated with timing of surgery.

CONCLUSIONS

Patients with hematologic malignancies can safely undergo cholecystectomy. Length of postoperative stay for inpatients is associated with intraoperative blood transfusion.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Acute Cholecystitis Following Allogeneic Hematopoietic Stem Cell Transplantation: Clinical Features, Outcomes, Risk Factors, and Prediction Model

Acute cholecystitis (AC) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT); however, only limited information is available on its clinical features, outcomes, and risk management strategies. This retrospective, nested, case-control study included 6701 patients undergoing allo-HSCT at our center from January 2004 to June 2019. In total, 72 patients (1.1%) were diagnosed with AC; among these, acute acalculous cholecystitis had a slightly higher prevalence (42 patients, 58.3%). Patients with moderate and severe AC exhibited remarkably worse overall survival (P = .001) and non-relapse mortality (P = .011) than others. Survival of haploidentical HSCT recipients with AC was comparable to that for patients with human leukocyte antigen (HLA)-identical donors. Age ≥ 18 years, antecedent stage II to IV acute graft-versus-host disease, and total parenteral nutrition were identified as potential risk factors for AC following allo-HSCT, while haploidentical transplantations were not more susceptible to AC than HLA-identical HSCT. Based on these criteria, a risk score model was developed and validated to estimate the probability of AC following allo-HSCT. The model separates all patients into low-, intermediate-, and high-risk groups and thereby provides a basis for early detection of this complication in the management of allo-HSCT.

Sonographic Appearance of the Gallbladder in the Allogeneic Hematopoietic Stem Cell Transplant Population

OBJECTIVES

To determine whether gallbladder sonographic findings in hematopoietic stem cell (HSC) transplant patients can distinguish among hepatobiliary complications of HSC transplants (graft-versus-host disease [GVHD] and veno-occlusive disease) and biliary events (cholecystitis, cholangitis, and choledocholithiasis).

METHODS

All HSC transplant patients who underwent gallbladder sonography from 2009 through 2012 were identified. Complications and sonographic findings were recorded.

RESULTS

Of 124 patients, 66 (53.2%) had an event: 33 (50.0%) had GVHD; 22 (33.3%) had veno-occlusive disease; 6 (9.0%) had a biliary event; 4 (6.0%) had veno-occlusive disease and GVHD; and 1 (1.5%) had veno-occlusive disease and a biliary event. Of all patients, 115 (92.7%) had 1 or more sonographic findings in the gallbladder, with sludge being most common in all groups. In patients with veno-occlusive disease, the second and third most common findings were pericholecystic fluid and wall thickening. In patients with GVHD, distension was the second most common. Patients with biliary events all had distension, and half had pericholecystic fluid. Patients with veno-occlusive disease were significantly more likely to have wall thickening than those with GVHD or no event (77.2% versus 36.3%; P= .005; and 77.2% versus 37.9%; P= .002) and more likely to have pericholecystic fluid than patients with GVHD (95.5% versus 45.5%; P = .0001), a biliary event (95.5% versus 50%; P = .02), or no event (95.5% versus 29.3%; P = .0001). The positive predictive value of any finding was low for all groups because findings were common in patients with no event.

CONCLUSIONS

Sonographic abnormalities of the gallbladder after HSC transplants are common in patients with and without HSC transplant complications and in those with biliary events. No sonographic finding is useful to distinguish among complications in HSC transplant patients.

Treatment Modalities and Antimicrobial Stewardship Initiatives in the Management of Intra-Abdominal Infections

Antimicrobial stewardship programs (ASPs) focus on improving the utilization of broad spectrum antibiotics to decrease the incidence of multidrug-resistant Gram positive and Gram negative pathogens. Hospital admission for both medical and surgical intra-abdominal infections (IAIs) commonly results in the empiric use of broad spectrum antibiotics such as fluoroquinolones, beta-lactam beta-lactamase inhibitors, and carbapenems that can select for resistant organisms. This review will discuss the management of uncomplicated and complicated IAIs as well as highlight stewardship initiatives focusing on the proper use of broad spectrum antibiotics.