- Email: [email protected]
INCIDENCE OF CHOLELITHIASIS IN 125 CONTINENT URINARY DIVERSIONS
0022-5347/01/1656-1897/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 165, 1897–1899, June 2001 Printed in U.S.A.
INCIDENCE OF CHOLELITHIASIS IN 125 CONTINENT URINARY DIVERSIONS DANIEL G. HOLMES, GERALD Y. PARK, J. BRANTLEY THRASHER, DEBORAH KUEKER JOHN W. WEIGEL
AND
From the Section of Urology, University of Kansas Medical Center, Kansas City, Kansas
ABSTRACT
Purpose: Several studies in animals and humans have demonstrated that ileal resection has an increased association with gallstone formation. However, little reported data exist in regard to continent diversion, and the incidence and relative risk of gallstones. We describe a single institution, single surgeon (J. W. W.) experience with 125 modified Indiana pouch continent urinary diversions constructed in a 14-year period and the subsequent association with gallstones. Materials and Methods: We retrospectively reviewed the charts of 129 patients who underwent continent urinary diversion from March 1985 to August 1998 at our institution to assess postoperative cholelithiasis. Complete information was available in 125 of the 129 charts. All patients were followed yearly with ultrasound combined with telephone followup to ensure complete data. Results: Cholelithiasis was present in 32 of the 125 reviewable patients (25.6%), including 53 men and 72 women. Three men and 8 women who underwent previous or concomitant cholecystectomy for gallstones were excluded from study. Therefore, cholelithiasis developed in 21 of the 114 remaining patients (18.4%), including 5 males (4.3%) and 16 females (14%). Five of the 50 remaining men (10%) and 16 of the remaining 64 women (25%) had gallstones. Mean age at surgery was 43.5 years (range 19 to 73) and mean age at gallstone development was 45 years (range 23 to 77). Mean time from surgery to gallstone development was 3 years (range 1.1 to 5.5). Mean followup via chart review was 41 months (range 1 to 127). The recent telephone followup reached 83 of the 125 patients (66.4%). However, 20 of the 42 patients who were not reached by the telephone followup had had clinic appointments at our institution in the last 11⁄2 years for an overall 82.4% followup rate (103 of 125 patients). Of the 21 patients with cholelithiasis 17 were identified by chart review and 4 were identified by telephone followup. Conclusions: The recent literature indicates a 10% and 20% incidence of gallstones in American men and women, respectively. Previous reports support a potential increase in cholelithiasis in patients who undergo ileal resection. Our data indicate no increased risk of gallstones in patients who undergo modified Indiana pouch urinary diversion. However, longer followup is required to verify these findings. KEY WORDS: urinary diversion, cholelithiasis, ileum, metabolism
Several studies in animals and humans have demonstrated that ileal resection has an increased association with gallstone formation. It has been reported that up to 35% of patients with more than 100 cm. of ileum resected may have gallstones.1 However, little reported data exist in regard to continent urinary diversion, and the incidence and relative risk of gallstones.2, 3 However, it must be considered that to assess accurately this risk it must be compared to that in the general population. Recent literature indicates that the incidence of asymptomatic cholelithiasis in the American population is 10% in males and 20% in females.4 We describe a single institution, single surgeon (J. W. W.) experience with 125 modified Indiana pouch continent urinary diversions constructed in a 14-year period and the subsequent association with gallstones compared to the overall population. MATERIALS AND METHODS
We retrospectively reviewed the charts of 129 patients who underwent modified Indiana pouch continent urinary diversion from March 1985 to August 1998 at our institution. Complete data were available in 125 charts. In all patients a Accepted for publication January 12, 2001.
cecoileal continent urinary reservoir was created using the modified Indiana technique, as previously described by Rowland et al.5 A total of 26 to 30 cm. of right colon and cecum were completely detubularized. Appendectomy was routinely performed and 10 to 12 cm. of terminal ileum were isolated to form the efferent limb. Cecostomy tube and ureteral stent placement was also standard. In all cases abdominal ultrasound was performed on day 7 postoperatively before stent removal. No patients had gallstones at the time of ultrasound. Patients were followed with ultrasound yearly and with other followup laboratory studies, including complete blood count, creatinine, electrolytes and vitamin B12. Screening ultrasound assessed the upper tract and gallbladder. Many patients were followed initially at our tertiary care center and then released to another urologist for continued followup, as described. Correspondence with one of us (J. W. W.) and treatment of any complications comprised a portion of our data set for chart review. For completeness the chart review was combined with a telephone followup on gallstone development and/or symptoms. This followup was especially important for patients no longer followed at our institution.
1897
1898
INCIDENCE OF CHOLELITHIASIS IN 125 CONTINENT URINARY DIVERSIONS RESULTS
Cholelithiasis was present in 32 of the 125 patients (25.6%), including 53 men and 72 women. Three men and 8 women who underwent previous or concomitant cholecystectomy for gallstones were excluded from study. Therefore, cholelithiasis developed in 21 of the 114 remaining patients (18.4%), including 5 men (4.3%) and 16 women (14%). Five of the remaining 50 male patients (10%) and 16 of the remaining 64 female patients (25%) had cholelithiasis (fig. 1). Mean age at surgery was 43.5 years (range 19 to 73) and mean age at gallstone development was 45 years (range 23 to 77). Mean time from surgery to gallstone development was 3 years (range 1.1 to 5.5). Mean followup via chart review was 41 months (range 1 to 127). The recent telephone followup reached 83 of the 125 patients (66.4%). However, 20 of the 42 patients who were not reached by telephone followup had had clinic appointments at our institution in the last 11⁄2 years for an overall followup rate of 82.4% (103 of 125 patients) (fig. 2). Of the 21 patients with cholelithiasis 17 were identified by chart review and 4 were identified by telephone followup. Cholelithiasis was present in 8 of the 86 patients with 0 to 60, 13 of the 34 with 61 to 120 and 0 of the 5 with 121 to 168 months of followup. DISCUSSION
There are little data on continent urinary diversion, and the incidence and relative risk of gallstones.2, 3 Much available data on the complications of bowel resection or urine in contact with bowel were obtained from animal studies or patients with bowel disease and, thus, they are difficult to compare with the average population.6 Ileum is widely used alone or combined with cecum and ascending colon. The terminal ileum and ileocecal valve are particularly important for resorptive function, bowel emptying regulation and small bowel loss compensation.7 Experiments have shown that the ileocecal valve may increase intestinal transit time from 0.8 to 2.5 hours in humans.8 Resection of the ileocecal valve with the adjacent ileum or colon may enhance the effect of either type of resection alone.9, 10 Resecting up to 60 cm. of ileum is not believed to result in malabsorptive sequelae if the terminal ileum and ileocecal valve are intact.11, 12 However, if 60 to 100 of cm. ileum are resected, further changes in lipid metabolism occur.12 Lipid malabsorption is not severe and diarrhea in these cases is due to the cathartic action of bile acids in the colon because they inhibit sodium reabsorption, resulting in increased water loss.11, 13–17 Similarly the resection of greater than 100 cm. of ileum results in lipid malabsorption even with an intact terminal ileum and ileocecal valve due to severe bile acid malabsorption.18 However, resecting less than 60 cm. of ileum does not exclude the possibility of malabsorption in individuals.6 Normally a constant 2.5 to 5 gm. of bile acid are present that undergo 6 to 8 cycles daily through the enterohepatic circulation. Between 300 and 600 mg. of bile are excreted in the feces and a similar amount is synthesized in the liver. When fecal losses of bile acids become too great, the liver
FIG. 1. Percent of patients with gallstones after urinary diversion compared to normal population.
FIG. 2. Percent of patients followed in last 11⁄2 years. FU, followup.
cannot increase production to compensate, and so bile acid secretion is decreased, leading to fat maldigestion and malabsorption.13, 15–17, 19 Cholesterol, the primary constituent of most gallstones, normally remains in solution by mixed micelles of bile acids and phospholipids. A relative deficiency of bile acids due to interference with the enterohepatic circulation may result in an increased propensity for cholesterol to precipitate. It is thought that up to 35% of patients with more than 100 cm. of ileum resected may form gallstones.12 However, it should be considered that gallstone analysis after major ileal resection has shown that pigment rather than cholesterol is the major component.20 We describe a single institution, single surgeon (J. W. W) experience with 125 modified Indiana pouch continent urinary diversions created in a 14-year period and the subsequent association with gallstones. The recent literature indicates 10% and 20% incidence of gallstones in American men and women, respectively. Our telephone followup reached 83 of our 125 study patients (66.4%). However, 20 who were not of the 42 patients reached by telephone had had clinic appointments in the last 11⁄2 years, thereby, changing our overall followup rate to 82.4% (103 of 125 patients). A previous report supports a potential increase in cholelithiasis in patients who undergo ileal resection.1 Our data indicate no increased risk of gallstone formation in patients who have undergone modified Indiana pouch urinary diversion. However, longer followup is required to verify these findings. REFERENCES
1. Andersson, H., Bosaeus, I., Fasth, S. et al: Cholelithiasis and urolithiasis in Crohn’s disease. Scand J Gastroenterol, 22: 253, 1987 2. Kirsch, A. J. and Hensle, T. W.: Symptomatic cholelithiasis following continent urinary diversion using ileocolonic bowel segments. J Urol, 151: 859, 1994 3. Champetier, D. and Dubernard, P.: Cholelithiasis and ileocycocystoplasty. Prog Urol, 3: 5, 1993 4. Kratzer, W., Mason, R. A. and Kachele, V.: Prevalence of gallstones in sonographic surveys worldwide. J Clin Ultrasound, 27: 1, 1999 5. Rowland, R. G., Mitchell, M. E. and Bihrle, R.: The cecal ileal continent urinary reservoir. World J Urol, 3: 185, 1985 6. Mills, R. D. and Studer, U. E.: Metabolic consequences of continent urinary diversion. J Urol, 161: 1057, 1999 7. Borgstrom, B., Lundh, G. and Hofmann, A.: The site of absorption of conjugated bile salts in man. Gastroenterology, suppl., 54: 781, 1968 8. Mojaverian, P., Chan, K., Desai, A. et al: Gastrointestinal transit of solid indigestible capsule as measured by radiotelemetry and dual gamma scintigraphy. Pharmacol Res, 6: 719, 1989
INCIDENCE OF CHOLELITHIASIS IN 125 CONTINENT URINARY DIVERSIONS 9. Mitchell, J. E., Breuer, R. I., Zuckermann, L. et al: The colon influences ileal resection diarrhea. Dig Dist Sci, 25: 33, 1980 10. Gazet, J. C.: The surgical significance of the ileo-caecal junction. Ann R Coll Surg Engl, 43: 19, 1968 11. Ileal resection and bile salt metabolism. JAMA, 215: 101, 1971 12. Miettinen, T. A.: Relationship between fecal bile acids, absorption of fat and vitamin B12 and serum lipids in patients with ileal resections. Eur J Clin Invest, 1: 452, 1971 13. Woodbury, J. F. and Kern, F., Jr.: Fecal excretion of bile acids: a new technique for studying bile acid kinetics in patients with ileal resection. J Clin Invest, 50: 2531, 1971 14. Koivisto, P. and Miettinen, T. A.: Adaptation of cholesterol and bile acid metabolism and vitamin B12 absorption in the longterm follow-up after partial ileal bypass. Gastroenterology, 90: 984, 1986 15. Aldini, R., Roda, A., Festi, D. et al: Bile acid malabsorption and
16. 17. 18. 19.
20.
1899
bile acid diarrhea in intestinal resection. Dig Dis Sci, 27: 495, 1982 Cummings, J. H., James, W. P. and Wiggins, H. S.: Role of colon in ileal-resection diarrhea. Lancet, 1: 344, 1973 Durrans, D., Wujanto, R., Carroll, R. N. et al: Bile acid malabsorption: a complication of conduit surgery. Br J Urol, 64: 485, 1989 Hofmann, A. F.: Bile acid malabsorption caused by ileal resection. Arch Intern Med, 130: 597, 1972 Neal, D. E., Williams, N. S., Barker, M. C. et al: The effect of resection of the distal ileum on gastric emptying, small bowel transit and absorption after proctocolectomy. Br J Surg, 71: 666, 1984 Pitt, H. A., Lewinski, M. A., Muller, E. L. et al: Ileal resectioninduced gallstones: altered bilirubin or cholesterol metabolism? Surgery, 96: 154, 1984
Vol. 165, 1897–1899, June 2001 Printed in U.S.A.
INCIDENCE OF CHOLELITHIASIS IN 125 CONTINENT URINARY DIVERSIONS DANIEL G. HOLMES, GERALD Y. PARK, J. BRANTLEY THRASHER, DEBORAH KUEKER JOHN W. WEIGEL
AND
From the Section of Urology, University of Kansas Medical Center, Kansas City, Kansas
ABSTRACT
Purpose: Several studies in animals and humans have demonstrated that ileal resection has an increased association with gallstone formation. However, little reported data exist in regard to continent diversion, and the incidence and relative risk of gallstones. We describe a single institution, single surgeon (J. W. W.) experience with 125 modified Indiana pouch continent urinary diversions constructed in a 14-year period and the subsequent association with gallstones. Materials and Methods: We retrospectively reviewed the charts of 129 patients who underwent continent urinary diversion from March 1985 to August 1998 at our institution to assess postoperative cholelithiasis. Complete information was available in 125 of the 129 charts. All patients were followed yearly with ultrasound combined with telephone followup to ensure complete data. Results: Cholelithiasis was present in 32 of the 125 reviewable patients (25.6%), including 53 men and 72 women. Three men and 8 women who underwent previous or concomitant cholecystectomy for gallstones were excluded from study. Therefore, cholelithiasis developed in 21 of the 114 remaining patients (18.4%), including 5 males (4.3%) and 16 females (14%). Five of the 50 remaining men (10%) and 16 of the remaining 64 women (25%) had gallstones. Mean age at surgery was 43.5 years (range 19 to 73) and mean age at gallstone development was 45 years (range 23 to 77). Mean time from surgery to gallstone development was 3 years (range 1.1 to 5.5). Mean followup via chart review was 41 months (range 1 to 127). The recent telephone followup reached 83 of the 125 patients (66.4%). However, 20 of the 42 patients who were not reached by the telephone followup had had clinic appointments at our institution in the last 11⁄2 years for an overall 82.4% followup rate (103 of 125 patients). Of the 21 patients with cholelithiasis 17 were identified by chart review and 4 were identified by telephone followup. Conclusions: The recent literature indicates a 10% and 20% incidence of gallstones in American men and women, respectively. Previous reports support a potential increase in cholelithiasis in patients who undergo ileal resection. Our data indicate no increased risk of gallstones in patients who undergo modified Indiana pouch urinary diversion. However, longer followup is required to verify these findings. KEY WORDS: urinary diversion, cholelithiasis, ileum, metabolism
Several studies in animals and humans have demonstrated that ileal resection has an increased association with gallstone formation. It has been reported that up to 35% of patients with more than 100 cm. of ileum resected may have gallstones.1 However, little reported data exist in regard to continent urinary diversion, and the incidence and relative risk of gallstones.2, 3 However, it must be considered that to assess accurately this risk it must be compared to that in the general population. Recent literature indicates that the incidence of asymptomatic cholelithiasis in the American population is 10% in males and 20% in females.4 We describe a single institution, single surgeon (J. W. W.) experience with 125 modified Indiana pouch continent urinary diversions constructed in a 14-year period and the subsequent association with gallstones compared to the overall population. MATERIALS AND METHODS
We retrospectively reviewed the charts of 129 patients who underwent modified Indiana pouch continent urinary diversion from March 1985 to August 1998 at our institution. Complete data were available in 125 charts. In all patients a Accepted for publication January 12, 2001.
cecoileal continent urinary reservoir was created using the modified Indiana technique, as previously described by Rowland et al.5 A total of 26 to 30 cm. of right colon and cecum were completely detubularized. Appendectomy was routinely performed and 10 to 12 cm. of terminal ileum were isolated to form the efferent limb. Cecostomy tube and ureteral stent placement was also standard. In all cases abdominal ultrasound was performed on day 7 postoperatively before stent removal. No patients had gallstones at the time of ultrasound. Patients were followed with ultrasound yearly and with other followup laboratory studies, including complete blood count, creatinine, electrolytes and vitamin B12. Screening ultrasound assessed the upper tract and gallbladder. Many patients were followed initially at our tertiary care center and then released to another urologist for continued followup, as described. Correspondence with one of us (J. W. W.) and treatment of any complications comprised a portion of our data set for chart review. For completeness the chart review was combined with a telephone followup on gallstone development and/or symptoms. This followup was especially important for patients no longer followed at our institution.
1897
1898
INCIDENCE OF CHOLELITHIASIS IN 125 CONTINENT URINARY DIVERSIONS RESULTS
Cholelithiasis was present in 32 of the 125 patients (25.6%), including 53 men and 72 women. Three men and 8 women who underwent previous or concomitant cholecystectomy for gallstones were excluded from study. Therefore, cholelithiasis developed in 21 of the 114 remaining patients (18.4%), including 5 men (4.3%) and 16 women (14%). Five of the remaining 50 male patients (10%) and 16 of the remaining 64 female patients (25%) had cholelithiasis (fig. 1). Mean age at surgery was 43.5 years (range 19 to 73) and mean age at gallstone development was 45 years (range 23 to 77). Mean time from surgery to gallstone development was 3 years (range 1.1 to 5.5). Mean followup via chart review was 41 months (range 1 to 127). The recent telephone followup reached 83 of the 125 patients (66.4%). However, 20 of the 42 patients who were not reached by telephone followup had had clinic appointments at our institution in the last 11⁄2 years for an overall followup rate of 82.4% (103 of 125 patients) (fig. 2). Of the 21 patients with cholelithiasis 17 were identified by chart review and 4 were identified by telephone followup. Cholelithiasis was present in 8 of the 86 patients with 0 to 60, 13 of the 34 with 61 to 120 and 0 of the 5 with 121 to 168 months of followup. DISCUSSION
There are little data on continent urinary diversion, and the incidence and relative risk of gallstones.2, 3 Much available data on the complications of bowel resection or urine in contact with bowel were obtained from animal studies or patients with bowel disease and, thus, they are difficult to compare with the average population.6 Ileum is widely used alone or combined with cecum and ascending colon. The terminal ileum and ileocecal valve are particularly important for resorptive function, bowel emptying regulation and small bowel loss compensation.7 Experiments have shown that the ileocecal valve may increase intestinal transit time from 0.8 to 2.5 hours in humans.8 Resection of the ileocecal valve with the adjacent ileum or colon may enhance the effect of either type of resection alone.9, 10 Resecting up to 60 cm. of ileum is not believed to result in malabsorptive sequelae if the terminal ileum and ileocecal valve are intact.11, 12 However, if 60 to 100 of cm. ileum are resected, further changes in lipid metabolism occur.12 Lipid malabsorption is not severe and diarrhea in these cases is due to the cathartic action of bile acids in the colon because they inhibit sodium reabsorption, resulting in increased water loss.11, 13–17 Similarly the resection of greater than 100 cm. of ileum results in lipid malabsorption even with an intact terminal ileum and ileocecal valve due to severe bile acid malabsorption.18 However, resecting less than 60 cm. of ileum does not exclude the possibility of malabsorption in individuals.6 Normally a constant 2.5 to 5 gm. of bile acid are present that undergo 6 to 8 cycles daily through the enterohepatic circulation. Between 300 and 600 mg. of bile are excreted in the feces and a similar amount is synthesized in the liver. When fecal losses of bile acids become too great, the liver
FIG. 1. Percent of patients with gallstones after urinary diversion compared to normal population.
FIG. 2. Percent of patients followed in last 11⁄2 years. FU, followup.
cannot increase production to compensate, and so bile acid secretion is decreased, leading to fat maldigestion and malabsorption.13, 15–17, 19 Cholesterol, the primary constituent of most gallstones, normally remains in solution by mixed micelles of bile acids and phospholipids. A relative deficiency of bile acids due to interference with the enterohepatic circulation may result in an increased propensity for cholesterol to precipitate. It is thought that up to 35% of patients with more than 100 cm. of ileum resected may form gallstones.12 However, it should be considered that gallstone analysis after major ileal resection has shown that pigment rather than cholesterol is the major component.20 We describe a single institution, single surgeon (J. W. W) experience with 125 modified Indiana pouch continent urinary diversions created in a 14-year period and the subsequent association with gallstones. The recent literature indicates 10% and 20% incidence of gallstones in American men and women, respectively. Our telephone followup reached 83 of our 125 study patients (66.4%). However, 20 who were not of the 42 patients reached by telephone had had clinic appointments in the last 11⁄2 years, thereby, changing our overall followup rate to 82.4% (103 of 125 patients). A previous report supports a potential increase in cholelithiasis in patients who undergo ileal resection.1 Our data indicate no increased risk of gallstone formation in patients who have undergone modified Indiana pouch urinary diversion. However, longer followup is required to verify these findings. REFERENCES
1. Andersson, H., Bosaeus, I., Fasth, S. et al: Cholelithiasis and urolithiasis in Crohn’s disease. Scand J Gastroenterol, 22: 253, 1987 2. Kirsch, A. J. and Hensle, T. W.: Symptomatic cholelithiasis following continent urinary diversion using ileocolonic bowel segments. J Urol, 151: 859, 1994 3. Champetier, D. and Dubernard, P.: Cholelithiasis and ileocycocystoplasty. Prog Urol, 3: 5, 1993 4. Kratzer, W., Mason, R. A. and Kachele, V.: Prevalence of gallstones in sonographic surveys worldwide. J Clin Ultrasound, 27: 1, 1999 5. Rowland, R. G., Mitchell, M. E. and Bihrle, R.: The cecal ileal continent urinary reservoir. World J Urol, 3: 185, 1985 6. Mills, R. D. and Studer, U. E.: Metabolic consequences of continent urinary diversion. J Urol, 161: 1057, 1999 7. Borgstrom, B., Lundh, G. and Hofmann, A.: The site of absorption of conjugated bile salts in man. Gastroenterology, suppl., 54: 781, 1968 8. Mojaverian, P., Chan, K., Desai, A. et al: Gastrointestinal transit of solid indigestible capsule as measured by radiotelemetry and dual gamma scintigraphy. Pharmacol Res, 6: 719, 1989
INCIDENCE OF CHOLELITHIASIS IN 125 CONTINENT URINARY DIVERSIONS 9. Mitchell, J. E., Breuer, R. I., Zuckermann, L. et al: The colon influences ileal resection diarrhea. Dig Dist Sci, 25: 33, 1980 10. Gazet, J. C.: The surgical significance of the ileo-caecal junction. Ann R Coll Surg Engl, 43: 19, 1968 11. Ileal resection and bile salt metabolism. JAMA, 215: 101, 1971 12. Miettinen, T. A.: Relationship between fecal bile acids, absorption of fat and vitamin B12 and serum lipids in patients with ileal resections. Eur J Clin Invest, 1: 452, 1971 13. Woodbury, J. F. and Kern, F., Jr.: Fecal excretion of bile acids: a new technique for studying bile acid kinetics in patients with ileal resection. J Clin Invest, 50: 2531, 1971 14. Koivisto, P. and Miettinen, T. A.: Adaptation of cholesterol and bile acid metabolism and vitamin B12 absorption in the longterm follow-up after partial ileal bypass. Gastroenterology, 90: 984, 1986 15. Aldini, R., Roda, A., Festi, D. et al: Bile acid malabsorption and
16. 17. 18. 19.
20.
1899
bile acid diarrhea in intestinal resection. Dig Dis Sci, 27: 495, 1982 Cummings, J. H., James, W. P. and Wiggins, H. S.: Role of colon in ileal-resection diarrhea. Lancet, 1: 344, 1973 Durrans, D., Wujanto, R., Carroll, R. N. et al: Bile acid malabsorption: a complication of conduit surgery. Br J Urol, 64: 485, 1989 Hofmann, A. F.: Bile acid malabsorption caused by ileal resection. Arch Intern Med, 130: 597, 1972 Neal, D. E., Williams, N. S., Barker, M. C. et al: The effect of resection of the distal ileum on gastric emptying, small bowel transit and absorption after proctocolectomy. Br J Surg, 71: 666, 1984 Pitt, H. A., Lewinski, M. A., Muller, E. L. et al: Ileal resectioninduced gallstones: altered bilirubin or cholesterol metabolism? Surgery, 96: 154, 1984