# Five Cases of Biliary Peritonitis Due to Bile Leakage From the Gallbladder During Postoperative Hospitalization After Cardiovascular Surgery

## TL;DR

This paper reports five cases of biliary peritonitis caused by gallbladder bile leakage following cardiovascular surgeries, highlighting the importance of early diagnosis and treatment.

## Contribution

The paper identifies a potential association between cardiovascular surgery and gallbladder bile leakage, emphasizing the need for clinical awareness in postoperative care.

## Key findings

- Five cases of biliary peritonitis occurred during postoperative hospitalization after cardiovascular surgeries.
- Early diagnosis and treatment led to successful outcomes in all five cases.
- Preoperative CT showed atherosclerotic changes in the aorta, possibly contributing to gallbladder ischemia.

## Abstract

Biliary peritonitis due to bile leakage from the gallbladder is considered a rare clinical entity. However, at our institution, we encountered five such cases between January 2018 and December 2024, all occurring during the postoperative course following cardiovascular surgery. This report presents clinical backgrounds, preoperative and intraoperative findings, and histopathological characteristics of these cases. We present five cases of biliary peritonitis due to bile leakage from the gallbladder. Four cases were acalculous cholecystitis, and three patients lacked abdominal symptoms. All cases developed during hospitalization after cardiovascular surgeries, including total arch replacement (two cases), ventricular septal rupture repair (one case), femoral-popliteal artery bypass (one case), and endovascular aortic repair (EVAR) (one case). Preoperative imaging showed gallbladder wall thinning and reduced contrast enhancement, while intraoperative findings revealed ischemic changes on the gallbladder serosa with bile leakage. Four patients underwent laparoscopic cholecystectomy, and one underwent open surgery. Histopathological examination revealed necrotic changes extending to the subserosal layer or involving the full thickness of the gallbladder wall at the site of bile leakage. This condition is reported to be difficult to diagnose due to minimal abdominal symptoms. In our series, all five cases developed during the postoperative course of cardiovascular surgery but were successfully diagnosed and treated early, resulting in the survival of all patients. Preoperative CT showed advanced atherosclerotic changes in the aorta, with stenosis and calcifications, particularly in the proximal cystic artery. The combination of cardiovascular risk and systemic stress after major surgery may have contributed to the onset of this condition. Recognizing this condition may lead to early diagnosis and appropriate treatment interventions. Although rare, biliary peritonitis due to bile leakage from the gallbladder can occur with notable frequency during the postoperative course of cardiovascular surgery. Understanding its characteristic imaging findings and clinical context is important for early diagnosis and appropriate management.