The role of prophylactic cholecystectomy in the short-bowel syndrome

J. S. Thompson
Department of Surgery, University of Nebraska Medical Center, Omaha, USA.

OBJECTIVES: To determine the factors associated with cholelithiasis and define the role of prophylactic cholecystectomy in the short-bowel syndrome. DESIGN: Retrospective clinical review of cohort of consecutive patients. SETTING: Tertiary care, academic medical center. PATIENTS: Fifty adult (age, > 16 years) patients with intestinal remnants less than 180 cm were evaluated over a 15-year period. MAIN OUTCOME MEASURES: Incidence and natural history of cholelithiasis, postoperative morbidity, and mortality rates. RESULTS: Prophylactic cholecystectomy was performed in 5 patients (10%). Ten patients (20%) died within 20 days without evidence of gallstones. Eleven (31%) of the other 35 patients at risk developed biliary disease; 6 of these patients had inflammatory complications or common bile duct stones. Biliary disease was more likely (P < .05) in patients with intestinal remnant length less than 120 cm (47% vs 13%), an absent ileocecal junction (41% vs 0%), long-term total parenteral nutrition (45% vs 13%), and Crohn's disease (67% vs 24%). Patients with mesenteric vascular disease had high initial mortality (50%) and a 38% incidence of biliary disease. Patients with cancer and/or irradiation had a lower initial mortality (7%) and no biliary disease. Patients with benign conditions had a significant incidence of cholelithiasis (57%). CONCLUSIONS: Patients with the short-bowel syndrome have a significant risk for cholelithiasis if the intestinal remnant length is less than 120 cm, total parenteral nutrition is required, and the terminal ileum is resected. Prophylactic cholecystectomy is indicated in patients with benign conditions and anticipated long-term survival. It should also be considered in patients with mesenteric vascular disease who, despite significantly shortened survival, may have a high incidence of early biliary problems.