Laparoscopic two-stage procedure for gallstone ileus.

Gallstone is a rare cause of bowel obstruction and is associated with high rates of morbidity and mortality. Here, we report a case of gallstone ileus treated by laparoscopic two-stage procedure. A 65-year-old man, without a history of any surgery, presented to our hospital with abdominal pain and vomiting. His abdominal computed tomography revealed gallstone ileus with cholecystoduodenal fistula. Then, enterolithotomy was performed as an emergency laparoscopic surgery. After 1 year of the surgery, a second laparoscopic procedure was performed for cholecystectomy and fistula closure. The patient was discharged on the 7th postoperative day. Laparoscopic two-stage procedure is a safe and an efficient approach for the management of gallstone ileus. This definitive treatment is minimally invasive, thereby suitable for treating elderly patients.

INTRODUCTION

Gallstone ileus is described as mechanical obstruction resulting from the impaction of a large gallstone through the biliary-enteric fistula. It is a rare complication of cholecystitis, accounting for 1%–3% of all patients who undergo surgery for bowel obstruction.[1] As per the latest nationwide survey in the US, gallstone ileus is still associated with high rates of morbidity and mortality.[2] In many cases, gallstone is impacted in the small intestine through a cholecystoduodenal fistula; in such cases, one-stage operation is generally avoided and two-stage operation is preferred. Enterolithotomy alone is initially performed, followed by subsequent cholecystectomy and fistula closure if the cholecystoduodenal fistula is not spontaneously closed. One-stage procedure is associated with higher mortality and morbidity than two-stage laparotomy; therefore, one-stage procedure has been performed in only 19% of gallstone ileus cases.[2] This scenario emphasises the need for a minimally invasive treatment for gallstone ileus. Recently, there have been several reports on laparoscopic enterolithotomy.[3] However, there is only one report stating that both stages of operation were laparoscopically performed in a two-stage procedure for colonic gallstone ileus.[4] An appropriate method for two-stage treatment for gallstone ileus remains unclear. Here, we report a novel method for gallstone ileus treated using laparoscopic two-stage procedure.

CASE REPORT

A 65-year-old man visited our hospital with abdominal pain and vomiting. He had type 2 diabetes mellitus and no history of surgery. His physical examination revealed a body temperature of 36.3°C, blood pressure of 126/90 mmHg and pulse rate of 90 bpm. He showed slight tenderness to palpation in the lower right abdomen. His laboratory findings were unremarkable. Plain X-ray imaging of the abdomen revealed dilated loops of the small intestine. Enhanced computed tomography showed the evidence of an intestinal obstruction in the pelvic area, with dilatation of the small intestine at the proximal side [Figure 1]. A 5-cm stone was detected in the small intestine, and pneumobilia was observed in the gallbladder. Based on these clinical findings, the patient was diagnosed with gallstone ileus, and an emergency laparoscopic surgery was performed.

Figure 1

Enhanced computed tomography showing intestinal obstruction in the pelvic area, with dilatation of the small intestine at the proximal side. A 5-cm round opacity (arrowheads) in the small intestine and pneumobilia (arrow) can be seen

Three 5-mm port approaches and a 5-mm laparoscope were applied to explore the abdomen. The site of obstruction was identified by locating the terminal ileum and tracing it proximally. Thereafter, the intestines were lifted up through a 4-cm small abdominal incision, and the gallstone was extracted using enterotomy [Figure 2]. The patient had no post-operative complications and was discharged after 7 days. No recurrence has been observed until post-operative 1 year.

Figure 2

By laparoscopic assistance, the gallstone was extracted using enterotomy

Esophagogastroduodenoscopy performed after 1 year of the surgery revealed a remnant cholecystoduodenal fistula. Therefore, a second elective operation for cholecystectomy and fistula closure was performed using laparoscopy.

First, a trocar was placed in the umbilical position under optical guidance; then, two additional trocars were added to the upper right quadrant and another two trocars to the upper left quadrant. Examination of the right upper abdomen revealed adhesions in the second portion of the duodenum to a chronically inflamed gallbladder. Laparoscopic dissection of the adhesions allowed the identification of the cholecystoduodenal fistula [Figure 3]. The fistula was closed using an automatic suture device at the side of the duodenum. Finally, laparoscopic cholecystectomy was performed. The post-operative course was uneventful, and the patient was discharged on the 6th post-operative day.

Figure 3

Laparoscopic surgery showing the cholecystoduodenal fistula. A tape was put through the dorsal side of the fistula

DISCUSSION

Gallstone ileus is caused by the migration of large gallstones from the gallbladder or common bile duct into the gut by direct passage through a cholecystoenteric fistula. Biliary-enteric fistulas occur in the setting of inflammation, generally as an episode of acute cholecystitis, and are a result of the formation of adhesions between the gallbladder and a nearby portion of the bowel. Approximately 75% of these fistulas are cholecystoduodenal, whereas only 10%–20% are cholecystocolonic.[5] Regarding the location of impaction, the ileum is the major site, whereas the duodenum, colon and stomach are rare.[3] There are three treatment modalities for the surgical management of gallstone ileus: (i) enterolithotomy alone with stone extraction; (ii) two-stage procedure, involving enterotomy followed by cholecystectomy and fistula closure and (iii) one-stage procedure, involving enterotomy, stone extraction, cholecystectomy and fistula closure. The optimal surgical procedure for gallstone ileus remains debatable. Recently, in a case of gallstone impacted to the small intestine through the cholecystoduodenal fistula, a two-stage procedure is performed if the patient does not have any comorbidity. Depending on the clinical status of the patient, enterolithotomy alone or one-stage procedure is selected. In case of remnant cholecystoduodenal fistula, the patient is at the risk of retrograde cholangitis, reoccurrence of gallstone ileus and carcinogenesis.[67] Therefore, enterolithotomy alone is associated with these risks. In contrast, although one-stage procedure reduces the abovementioned risks, it is associated with higher morbidity and mortality than those in enterolithotomy alone.[12] The two-stage procedure offers both the advantages. The first operation (enterotomy and stone extraction) is often performed in emergency cases. Because many patients with gallstone ileus are elderly and have comorbidities and poor general health condition, the first operation requires a shorter duration and minimal invasiveness. The use of laparoscopic surgery in acute small bowel obstruction has been associated with a shorter postoperative hospital stay and lower morbidity than that in laparotomy.[8] We can expect spontaneous closure of cholecystduodenal fistula after the first procedure. Räf and Spangen reported that there are some cases of spontaneous closure of cholecystduodenal fistula and that elective cholecystectomy and fistula repair should be performed during the quiet period i.e., 3–6 months after enterolithotomy, for gallstone ileus.[9] Therefore, in our case, 6 months after enterolithotomy, cholecystduodenal fistula still persisted, and we suggested the second-stage procedure for this patient. In accordance with the patient's wishes, the second operation (cholecystectomy and fistula closure) was performed 1 year after enterolithotomy. As the downside of this approach, during the interval, we need to look out for symptoms of cholangitis and recurrence of gallstone ileus. In this patient, these symptoms were not observed by the time of the second operation. The second operation is performed as an elective and definitive surgery. In this case, we successfully performed the second procedure using laparoscopy. Some researchers have concluded that laparoscopic surgery for the treatment of cholecystoenteric fistula is equivalent to laparotomy in uncomplicated cases if performed by experienced laparoscopic surgeons.[410] Thus, laparoscopic two-stage procedure was found to be an efficient and safe treatment approach for the management of gallstone ileus, with reduced hospital stay duration. Moreover, this procedure is minimally invasive and requires less time for operation at the first stage (enterolithotomy) than that required for the one-stage procedure. Hence, it is suitable for treating elderly patients or patients with comorbidities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.