Gastric outlet obstruction by a lost gallstone: Case report and literature review

Current evidence on the diagnosis and management of spilled gallstones after laparoscopic cholecystectomy

BACKGROUND

Despite improvements in intraoperative and postoperative outcomes of laparoscopic cholecystectomy (LC), spilled gallstones (SGs) after LC remain a significant yet often overlooked complication, occurring in 1% to 40% of cases. This review discusses the most recent updates regarding the risk factors, presentations, complications, diagnosis, management, and prognosis of SGs after LC.

METHODS

A comprehensive systematic review was conducted using MEDLINE/PubMed, Google Scholar, Cochrane Library, and the Web of Science databases, with the range of search dates being between January 2015 and July 2024, regarding SG incidence, management, and complications.

RESULTS

Risk factors for SGs after LC include intraoperative gallbladder perforation because of poor operational environment, quantity, size, and type of stone (pigment, cholesterol rich, or mixed); presence of adhesions or anatomic variations; and insufficient surgical training. Of note, 60% of SG complications are abscesses from bacterial infections, which can progress to peritonitis, fistulas, lung/liver abscesses, and choledocholithiasis. SGs were associated with delayed presentation of unexpected clinical problems, with even diagnosis. Although treatment depends on the severity of the complication, when SGs are identified through imaging, often ultrasound and computed tomography, minimally invasive approaches and antibiotic courses are viable first-line approaches.

CONCLUSION

Although LC-associated spillage of gallstones is rare, the complications can be a serious cause of morbidity. Therefore, proper notification of operative complications, a high index of suspicion for patients with a previous history of LC, and awareness of appropriate diagnostic modalities are key variables for the early diagnosis and prevention of SG-related complications.

Lost gallstones during laparoscopic cholecystectomy as a common but underestimated complication-case report and review of the literature

Introduction

Laparoscopic cholecystectomy (LC) represents one of the most commonly performed routine abdominal surgeries. Nevertheless, besides bile duct injury, problems caused by lost gallstones represent a heavily underestimated and underreported possible late complication after LC.

Methods

Case report of a Clavien-Dindo IVb complication after supposedly straightforward LC and review of all published case reports on complications from lost gallstones from 2000-2022.

Case Report

An 86-year-old patient developed a perihepatic abscess due to lost gallstones 6 months after LC. The patient had to undergo open surgery to successfully drain the abscess. Reactive pleural effusion needed additional drainage. Postoperative ICU stay was 13 days. The patient was finally discharged after 33 days on a geriatric remobilization ward and died 12 months later due to acute cardiac decompensation.

Conclusion

Intraabdominal abscess formation due to spilled gallstones may present years after LC as a late complication. Surgical management in order to completely evacuate the abscess and remove all spilled gallstones may be required, which could be associated with high morbidity and mortality, especially in elderly patients. Regarding the overt underreporting of gallstone spillage in case of postoperative gallstone-related complications, focus need be put on precise reporting of even apparently innocuous complications during LC.

Consequences of the spilled gallstones during laparoscopic cholecystectomy: a systematic review

INTRODUCTION

Complications secondary to spilled gallstones can be classified in the category of disease of medical progress because prior to advent of laparoscopic cholecystectomy very few reports published on the topic. The aim of the present study was to investigate the predisposing factors and the complication rate of spilled gallstones during laparoscopic cholecystectomy over the past 21 years.

METHODS

Embase, Pubmed, Medline, Google scholar and Cochrane library were systematically searched for pertinent literature.

RESULTS

Seventy five out of 181 articles were selected including 85 patients; of those 38% were men and 62% women. The median age of the cohort was 64 years old and ranged between 33 and 87 years. Only 23(27%) of the authors reported the incident of spillage of the gallstones during the operation. Time of onset of symptoms varied widely from the second postoperative day to 15 years later. Ten of 85 patients were asymptomatic and diagnosed with spilled gallstones incidentally. The rest of the patients presented with complications of severe morbidity and almost, 87% of the patients needed to be treated with surgical intervention and 12% with US ± CT scan guidance drainage. Only one perioperative death reported.

CONCLUSIONS

Symptomatic patients with lost gallstones present with severe morbidity complications and required mostly major surgical procedures. Therefore, standardisation of the management of spilled gallstones is needed urgently. Hospitals need to review their policy with audits and recommendations and clinical guidelines are needed urgently.

Rare case of gallbladder mucocele causing gastric outlet obstruction treated with cholecystectomy

INTRODUCTION

Gallstone(s) impacted at the distal small bowel causing intestinal obstruction as a result of cholecystoenteric fistula is a well-known, albeit uncommon surgical condition. The rare Bouveret's Syndrome, which refers to the proximal impaction of gallstone(s) in the duodenum or pylorus resulting in the gastric outlet obstruction (GOO), has also been described in the literature. However, gallbladder mucocele with extrinsic compression of the duodenum and/or pylorus causing GOO is a separate entity that is extremely rare.

PRESENTATION OF CASE

A patient who presented with loss of appetite and weight, with intermittent vomiting over a course of eight months was found to have GOO secondary to extrinsic duodenal compression from a large gallbladder mucocele. Surgical intervention in the form of cholecystectomy was performed, and the patient's symptoms resolved post-operatively.

DISCUSSION

We describe an extremely rare case of GOO, which can be easily corrected with cholecystectomy. Removal of the gallbladder removes the root cause of the issue, and should be first line therapy unless the patient is unfit for surgery.

CONCLUSION

This extremely rare cause of GOO should be recognized, and treated promptly with surgery if possible.