THE PRESENCE OF VASCULAR DISEASE IS ASSOCIATED WITH MORE SEVERE BILIARY INFECTIONS: A MULTIVARIATE ANALYSIS
Emanuel A. Jaramillo*1,2, Lygia Stewart1,2
1Surgery, University of California San Francisco, San Francisco, CA; 2San Francisco VA Health Care System, San Francisco, CA
Background
Patients with vascular disease are known to have a higher prevalence of comorbidities, contributing to their overall complexity. The relationship between vascular disease and biliary disease severity, however, has not been studied.
Aim
To evaluate the impact of vascular disease on biliary disease severity.
Methods
1044 patients with gallstone disease (SF VAMC, 1989-2021) were studied. Gallstones, bile, and blood (as applicable) were cultured. Clinical history and stone type recorded, CCI calculated. Illness severity classified as: none (no inflammatory manifestations), SIRS (fever, leukocytosis, tachycardia), Sev (abscess, cholangitis, empyema, gangrene), or Sepsis-MODS (bacteremia, hypotension, organ dysfunction-failure). Univariate and multivariate analysis (SPSS v. 27) was performed to identify correlations between vascular disease (Vasc) and illness severity, as well as previously-identified factors associated with severe biliary infections (sex, bacteria, pigment stones, age). Because of interactions between diabetes (DM) and Vasc disease, we examined cases with DM only, Vasc only, both DM and Vasc disease (Vasc-DM), and neither.
Results
Vascular disease (Vasc) was present in 372 (36%) cases. 178 (48%) of these cases had multiple vascular diseases. As a single entity the following vascular diseases were present: 285 (78%) CAD, 98 (26%) PAD, and 93 (25%) CVD. Vasc disease significantly correlated with male sex, presence of biliary bacteria, pigment gallstones, elevated CCI, and increased illness severity (all P<0.0001, Table). Diabetes (DM) was also associated with Vasc disease, and cases with both DM and Vasc had the most severe illnesses (Table). On multivariate analysis, age, male sex, choledocholithiasis, pigment stones, vascular disease, diabetes, and Vasc-DM correlated with illness severity. While increasing CCI was associated with Vasc disease, when low CCI (<3) and high CCI (>3) groups were compared, cases with Vasc disease and Vasc-DM had more severe illness in both CCI groups (Figure), suggesting a contribution from Vasc disease apart from overall morbidity. Also, among cases presenting with acute cholecystitis, Vasc disease correlated with more a severe illness (empyema, gangrene, perforation, abscess), (37% vs 65%, P<0.0001).
Conclusion
The presence of a vascular disease is associated with an increase in systemic and local illness severity when compared to non-vascular disease patients. Cases with the combination of diabetes and vascular disease had the most severe illnesses, including more sepsis/MODS and complicated acute cholecystitis. This study is one of the first to demonstrate the clinical significance of vascular disease on biliary disease severity, and the importance of the combination of diabetes and vascular disease. This information can be used optimize treatment strategies in these complex patients.
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