Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus

Gallstone ileus: report of two cases and a mini literature review

Gallstone ileus is a relatively rare complication of cholelithiasis, and an uncommon cause of small bowel obstruction most commonly seen in elderly and debilitated people with associated comorbidities. Symptoms of gallstone ileus are insidious and may be vague while the delay in diagnosis results in a high mortality rate. Herein we report two cases of gallstone ileus in elderly patients with complex medical history who presented at the emergency department with abdominal pain and distension, vomiting and fluid/electrolyte disorders due to cholecysto-enteric fistula and bowel obstruction.

Bouveret syndrome preceding classical gallstone ileus: a rare presentation of a cholecystoduodenal fistula

Bouveret syndrome is the rarest variant of gallstone ileus characterized by the passage and impaction of a gallstone through a bilioenteric fistula leading to gastric outlet obstruction. The documented movement of an impacted gallstone in Bouveret syndrome through the gastrointestinal tract has not been previously discussed in the literature. A 64-year-old man presented with acute on chronic epigastric pain, fevers, and vomiting. Abdominal computed tomography established a diagnosis of Bouveret syndrome. A trial of endoscopic gallstone extraction was unsuccessful. Laparoscopic gastrotomy and stone removal were later attempted, however, intraoperatively it was noted that the stone had migrated and was now impacted in the jejunum causing a small bowel obstruction. The clinical picture was now that of gallstone ileus. Laparoscopic enterolithotomy was performed successfully. This article discusses the radiological, endoscopic, and intraoperative findings in this rare case of Bouveret syndrome that had evolved into classical gallstone ileus following stone migration.

Mirizzi syndrome: Problems and strategies

Mirizzi syndrome is a serious complication of gallstone disease. It is caused by the impacted stones in the gallbladder neck or cystic duct. One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot's triangle. In our clinical practice, bile duct, branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum. The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct, all of which are hidden pitfalls for surgeons. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferable tools for the diagnosis of Mirizzi syndrome. Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum. Subtotal cholecystectomy is an easy, safe and definitive approach to Mirizzi syndrome. When combined with the application of ERCP, a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe. The objective of this review was to highlight its existing problems: (1) low preoperative diagnostic rate, (2) easy to damage bile duct and branches of right hepatic artery, and (3) high concomitant gallbladder carcinoma. Meanwhile, the review aimed to discuss the possible therapeutic strategies: (1) to enhance its preoperative recognition by imaging findings, and (2) to avoid potential pitfalls during surgery.

Gallstone ileus- A rare presentation in the era of rampant cholecystectomies

INTRODUCTION

Gallstone ileus is a rare but potentially dangerous complication of cholelithiasis and represents about 1 % of the total cases of small bowel obstruction (Balthazar and Schechter, 1978).

PRESENTATION OF CASE

We report a case of 40 years old female who presented with signs and symptoms of bowel obstruction. On further investigation, a diagnosis of gallstone ileus was established. She was managed by laparoscopy-assisted enterolithotomy.

DISCUSSION

Gallstone ileus, a form of mechanical intestinal obstruction, predominantly affects elderly females. Surgical management options includes enterolithotomy alone, two-staged enterolithotomy with delayed cholecystectomy and fistula repair, and single staged enterolithotomy and fistula repair. A laparoscopy-assisted enterolithotomy allows simultaneous direct diagnosis of gallstone ileus and assessment of pericholecystic adhesions along with cholecystoenteral fistula.

CONCLUSION

Laparoscopy-assisted enterolithotomy was chosen for managing gallstone ileus in this patient, omitting cholecystectomy and fistula repair due to dense adhesions. The patient remained symptom free for 6 months post-surgery, suggesting potential spontaneous closure of the cholecystoduodenal fistula, affirming the viability of this less invasive approach.

Management of complex acute biliary disease for the general surgeon: A narrative review

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

An authentic radiological triad of Rigler allowing the diagnosis of gallstone ileus: A case report

The Rigler's Triad consists by three radiological signs, including intestinal obstruction, pneumobilia, and an aberrant gallstone in the bowel. It is an inconstant triad considered being pathognomonic of gallstone ileus. Gallstone ileus is an exceptional complication of cholelithiasis due to the passage of one or more gallstones from the bile ducts into the lumen of the bowel through a biliodigestive fistula. We report the case of an 83-year-old female patient with a history of ischemic heart disease and an asymptomatic large gallstone. The patient was admitted to the emergency department for bowel obstruction, abdominal pain, and bilious vomiting. A clinical examination found a patient with an alteration in general condition and a distended abdomen with tenderness. An abdominal CT scan revealed Rigler's triad, allowing the diagnosis of gallstone ileus. A midline exploratory laparotomy was performed to find a giant gallstone blocked in the last ileum loop. A simple enterolithotomy was performed, allowing the extraction of giant lithiasis from an 8-cm major axis. The postoperative evolution was uneventful, and the patient was discharged 4 days after surgical treatment.

Case of single-balloon enteroscopy-assisted lithotripsy using a holmium:YAG laser for an impacted stone in the jejunum

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Duodenocolic and Cholecystocolonic Fistula: A Case Report of an Unusual Presentation

Laparoscopic cholecystectomy is the established standard of care for addressing symptomatic gallstones, typically representing a straightforward and uncomplicated surgical procedure. However, patients exhibiting variant anatomy or local inflammation can present challenges to the surgeon, potentially leading to complications. In this context, we present the case of a 55-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease at a different medical facility. Postoperatively, she was diagnosed with a case of duodenocolic fistula and cholecystocolonic fistula. Conservative treatment ensued with intravenous antibiotic administration, as well as enteral and parenteral feeding. Diagnosing cholecystocolonic fistula before surgery proves challenging, even with modern diagnostic and imaging tools. Despite its significance, there is limited information in the literature regarding the management of this infrequent finding. The approach to diagnosis and management is elaborated upon in the case report.

Mirizzi Syndrome-The Past, Present, and Future

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Mechanical Small Bowel Obstruction Due to Gallstone Ileus: Diagnostic Challenges and Surgical Management

Gallstone ileus is a true mechanical intestinal obstruction. It is caused by gallstone impaction in the gastrointestinal (GI) tract after eroding and passing through a bilioenteric fistula. Gallstones are frequently impacted in the terminal ileum. Computed tomography (CT) imaging is diagnostic and shows specific findings of dilated small bowel loops suggesting small bowel obstruction, pneumobilia, and impacted gallstone in the small bowel. Favorable outcome is achieved by having strong clinical suspicion, timely diagnosis, preoperative resuscitation, and early surgical intervention. The three available surgical procedures to relieve gallstone ileus are entrolithotomy alone; one-stage procedure of enterolithotomy, cholecystectomy, and fistula closure; or two-stage procedure of enterolithotomy followed by cholecystectomy. This article outlines the clinical presentation, diagnosis, resuscitation, and different surgical interventions of patients with gallstone ileus.

Colonic Perforation Secondary to Gallstone Impaction in the Sigmoid Colon

Introduction

Gallstone sigmoid ileus is a very rare manifestation of large bowel obstruction. Mainly, three conditions predispose the manifestation of the entity; in particular, an episode of cholecystitis causing cholecysto-colonic fistula; a large gallstone; and narrowing of the sigmoid colon secondary to diverticular disease or malignancy. Case Report. An 82-year-old man presented to the emergency department with a one-week history of severe constipation, tachypnoea, tachycardia, hypotension, and high lactate. Physical examination demonstrated cyanosed upper and lower extremities and palpation of the abdomen revealed signs of peritonism, abdominal distention, and guarding. Computerized tomography scan demonstrated perforation of the hollow viscus organ secondary to impaction of the large gallstone in the sigmoid colon. Laparotomy revealed sigmoid perforation and widespread feculent peritonitis. The patient underwent Hartmann's procedure. After the intervention gave concerns regarding the patient's haemodynamic stability, he was transferred to the intensive care unit. The patient passed away on the third postoperative day due to complications secondary to haemodynamic instability.

Conclusions

Patients with early diagnosed uncomplicated sigmoid gallstone ileus can be managed with endoscopic mechanical lithotripsy. In case of failure, open or laparoscopic enterolithotomy can be applied. However, when patients present with complications, surgery should not be delayed. In our case, Hartmann's procedure was an absolute indication due to sigmoid perforation and widespread feculent peritonitis.

An unusual case of gallstone ileus within the cecum and ascending colon: a case report

Gallstone ileus is a rare cause of intestinal obstruction. Due to long-standing inflammation of the gallbladder, fistulization can occur within nearby structures, most commonly to the duodenum or hepatic flexure of the colon. Through these fistulas, a stone can migrate and result in a small bowel obstruction or a large bowel obstruction. This case exemplifies the diagnosis and treatment of gallstone ileus, along with potential complications due to stone migration. Early recognition and treatment of gallstone ileus is important, as stone migration can lead to increased mortality with delayed diagnosis.

The Rolling Stone: Bouveret Syndrome Requiring Open Gastrotomy After Failing Electrohydraulic Lithotripsy

Bouveret syndrome (BS) is an extremely rare form of gallstone ileus where a stone travels through a biliary-enteric fistula and causes gastric outlet obstruction. A 92-year-old male presented with gastric outlet obstruction secondary to an impacted gallstone in the duodenal bulb seen on imaging. Endoscopic therapy failed twice due to the immense gallstone size, and an open gastrotomy was required to remove the stone. The procedure was successful; however, the patient, unfortunately, passed away days after the operation due to other hospital illnesses. BS should be considered in patients with advanced age and significant comorbidities presenting with gastric outlet obstruction.

Gallstone ileus: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Gallstone ileus (GI) is defined as the occlusion of the intestinal lumen due to the impaction of one or more gallstones. The optimal management of GI is not consensual. We report a rare case of GI with a successful surgical treatment for a 65 year-old-female.

CASE PRESENTATION

A 65 year-old-woman, presented with biliary colic pain and vomiting for three days. On examination, she had a distended tympanic abdomen. A computed tomography scan revealed signs of small bowel obstruction due to a jejunal gallstone. She had pneumobilia due to a cholecysto-duodenal fistula. We performed a midline laparotomy. We found a dilated and ischemic jejunum with false membranes regarding the migrated gallstone. We performed a jejunal resection with primary anastomosis. We performed cholecystectomy and closed the cholecysto-duodenal fistula at the same operative time. The postoperative course was uneventful.

CLINICAL DISCUSSION

We reported successful surgical treatment for GI. It was a one-step procedure. GI is a rare situation. Due to their restricted lumen, the terminal ileum and the ileocaecal valve are where GI occurs most commonly. GI appears usually in elderly patients with comorbidities. The clinical presentation is not specific. CT scan evokes the diagnosis with high specificity. The surgical management of GI is not consensual. In our case, we performed bowel resection due to the presence of an ischemic intestine.

CONCLUSION

GI is a rare situation. It appears usually in elderly patients with comorbidities. The clinical presentation is not specific. The surgical management of GI is not consensual.

Mirizzi Syndrome Type I: A Case Presentation

Mirizzi syndrome (MS) is a rare complication of chronic cholelithiasis. The syndrome describes gallstone obstruction of Hartmann's pouch or the cystic duct that extrinsically compresses the common hepatic duct, causing obstructive jaundice. In advanced cases, the gallstones may erode into the biliary tree creating a fistula, requiring prompt diagnosis and careful surgical management. We present a case of an 82-year-old female who presented with upper abdominal pain and jaundice, later diagnosed with suspected MS type I, and managed surgically. We aim to highlight MS type I because of the potential progression and damage to the bile duct, creating complications that may affect overall patient outcome.

Mirizzi syndrome complicated by type IV cholecystobiliary fistula to the right hepatic duct

Mirizzi syndrome is a rare complication of long-term chronic cholecystitis, characterized by extrinsic compression of the common hepatic duct that may progress to development of cholecystobiliary fistula. Here we report a case of a 38-year-old female patient who underwent laparoscopic cholecystectomy with intraoperative cholangiogram for acute cholecystitis and choledocholithiasis. Intraoperatively, the patient was found to have a Mirizzi syndrome complicated by cholecystobiliary fistula to the right hepatic duct. The gallbladder was successfully removed, cholelithiasis cleared and a ureteral stent was used in reconstruction. The patient was discharged on postoperative two and was doing well on routine follow-up. Ultimately, Mirizzi syndrome is a rare clinical entity that requires careful consideration during preoperative workup and a high suspicion when abnormal anatomy is encountered intraoperatively.

Reduced port laparoscopic subtotal cholecystectomy for Mirizzi syndrome with a bilio-biliary fistula: A case report

A 65-year-old male diagnosed with Mirizzi syndrome with a bilio-biliary fistula was referred to our department and underwent single-incision laparoscopic surgery with an assistant trocar. As typical laparoscopic cholecystectomy could not be performed due to the coexistence of a bilio-biliary fistula, we performed laparoscopic subtotal cholecystectomy as a bail-out procedure according to the recommendation of the recent Tokyo Guidelines (TG18). The neck of the remnant gallbladder could be easily sutured with the effective use of an assistant trocar, and the surgery was completed without any complications. The patient was discharged 5 days after surgery without any complications. While little has been reported on the efficacy of reduced port surgery for Mirizzi syndrome, our surgical approach, i.e. reduced port surgery with an assistant trocar, enabled secure and easy suturing as a bail-out procedure and seemed to be an efficient method that is both less-invasive and safe.

Gallstone Ileus: A Rare Cause of Mechanical Bowel Obstruction

A gallstone ileus is a rare cause of mechanical bowel obstruction, accounting for 1% to 4% of all cases. Twenty-five percent of the patients are 65 years of age or older and often present previous significant medical conditions. The authors report the case of an 87-year-old male patient, admitted with the diagnosis of community-acquired pneumonia, who later developed frequent episodes of biliary vomiting, intermittent constipation, and abdominal distension. Abdominal imaging (ultrasound and computed tomography (CT)) showed evidence of a localized inflammatory process in a small bowel loop but excluded vesicular lithiasis. After a failure in the medical approach with antibiotics, an exploratory laparotomy was performed, identifying the intestinal occlusion area, followed by an enterolithotomy at the specific area, and extraction of a 4 cm stone of acellular material. Posteriorly, the patient was treated for three weeks with a carbapenem and physical rehabilitation was promptly initiated with full recovery of his previous status. Gallstone ileus is a very challenging diagnosis and surgery is the treatment of choice. In elderly patients, it is important to promote prompt physical rehabilitation to prevent prolonged bed rest.

Acalculous variant of Mirizzi syndrome: Imaging and clinical characteristics

PURPOSE

Mirizzi Syndrome is a rare disease that causes biliary obstruction in the setting of an impacted stone in the gallbladder neck or Hartmann's Pouch which exerts mass effect on the common duct; however, we have noticed inflammatory biliary narrowing in the absence of an offending gallstone in the setting of acute cholecystitis. The purpose of this study is to report the clinical and MRCP findings in a series of 10 patients with this variant of Mirizzi Syndrome.

MATERIALS AND METHODS

A search of our institution's PACS and electronic medical record identified 10 patients with a diagnosis of acute cholecystitis and narrowing of the common duct on imaging in the absence of an impacted gallstone. Imaging and clinical findings were confirmed by two board-certified abdominal radiologists.

RESULTS

All patients presented with abdominal pain and an average elevated total bilirubin of 3.0 mg/dL. Seven patients had MRCP findings of complete narrowing of the CBD. Nine patients had intrahepatic biliary ductal dilation. All nine patients with gadoliniumenhanced MRCP displayed biliary wall thickening with enhancement adjacent to the gallbladder. Nine patients underwent cholecystectomy, one patient underwent percutaneous cholecystostomy. Average bilirubin upon discharge was within normal limits at 0.9 mg/dL after intervention. Two patients had follow-up MRCP showing resolution of biliary narrowing.

CONCLUSION

A variant of Mirizzi Syndrome occurs in the absence of an offending gallstone in the gallbladder neck or cystic duct to explain the biliary narrowing. We postulate that acute cholecystitis can cause a local inflammatory narrowing resulting in biliary obstruction.

Mirizzi Syndrome Type IV Successfully Treated with Peroral Single-operator Cholangioscopy-guided Electrohydraulic Lithotripsy: A Case Report with Literature Review

A 76-year-old man presented with liver dysfunction and intrahepatic bile duct dilatation. Imaging studies showed two large stones that had become impacted in the common hepatic duct, which was fused with the gallbladder. The patient was diagnosed with Mirizzi syndrome type IV. Hepaticojejunostomy and stone removal failed due to dense gallbladder adhesions involving the right hepatic artery. The bile flow was temporarily restored; however, the patient experienced cholangitis 16 months later. The stones were extracted via peroral single-operator cholangioscopy (SOC)-guided electrohydraulic lithotripsy. This is the first case in which stones were completely removed by SOC-guided treatment in a patient with Mirizzi syndrome type IV.

The Diagnosis and Management of Recurrent Gallstone Ileus: A Case Report

Gallstone ileus is one of the rare and insidious causes of small bowel obstruction, which should always be kept in mind by clinicians, especially when encountering older people with a history of gallstones disease. The high mortality and morbidity rate associated with the condition can be mostly attributed to delayed or misdiagnosis. Imaging modalities, particularly CT scans, play an important role in correct and timely diagnosis. We present the case of a 65-year-old man with a two-year history of colicky biliary pain, who had severe abdominal pain with obstructive symptoms for five days before admission. The diagnosis of gallstone ileus is made using CT scan findings. Enterolithotomy alone was performed three days later. A second, smaller migrated gallstone was also found, which excreted spontaneously. After 20 days, the patient achieved full recovery and was discharged.

Surgical Management of Cholecystoenteric Fistula in Patients With and Without Gallstone Ileus: An Experience of 29 Cases

Background

Cholecystoenteric fistula (CEF) is an uncommon complication of cholelithiasis. Here, we report our experience on diagnostic methods and surgical management of CEF patients with and without gallstone ileus (GI).

Methods

This is a retrospective cases series over an 11-year period (2011–2022). Data analyzed included preoperative characteristics, ultrasound, imaging features, operation findings and postoperative course.

Results

A total of 29 patients diagnosed with CEF were enrolled, 51.7% (15/29) of whom were female, with a median age of 66 years (range: 35–96 years). With regards to subtype distribution, seventeen patients had cholecystoduodenal fistula (CDF), six had cholecystoconlonic fistula (CCF), three exhibited cholecystogastric fistula (CGF), one CDF combination with CCF and two CDF combination with type I Mirizzi syndrome. Twelve patients presented with gallstone ileus, and received one stage procedure or simple Enterolithotomy. The median operation time and blood loss of 157 min (range: 65–360 min) and 40 ml (range: 10–450 ml), respectively. Surgical complications, evidenced by fistula recurrence, were recorded in three patients (3/22; 13.6%), while four (4/29; 13.8%) and one patient (1/29; 3.4%) presented with wound infection and residual stone in common bile duct, respectively. No deaths were reported in our study.

Conclusion

CEF is a rare complication of gallstone disease that is occasionally found during operation. To date, no consensus has been reached regarding efficacious treatment therapies for CEF patients. For a CEF patient with GI, one stage procedure should be selected prudently, while simple Enterolithotomy would be a mainstream choice for relieving bowel obstruction.

Surgical strategies for Mirizzi syndrome: A ten-year single center experience

BACKGROUND

Mirizzi syndrome (MS) remains a challenging biliary disease, and its low rate of preoperative diagnosis should be resolved. Moreover, technological advances have not resulted in decisive improvements in the surgical treatment of MS. Complex bile duct lesions due to MS make surgery difficult, especially when the laparoscopic approach is adopted. The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.

AIM

To analyze preoperative diagnostic methods and the safety, effectiveness, prognosis and related factors of surgical strategies for different types of MS.

METHODS

The clinical data of MS patients who received surgical treatment from January 1, 2010 to December 31, 2020 were retrospectively reviewed. Patients with malignancies, choledochojejunal fistula, lack of data and lost to follow-up were excluded. According to preoperative imaging examination records and documented intraoperative findings, the clinical types of MS were determined using the Csendes classification. The safety, effectiveness and long-term prognosis of surgical treatment in different types of MS, and their interactions with the clinical characteristics of patients were summarized.

RESULTS

Sixty-six patients with MS were included (34 males and 32 females). Magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) showed specific imaging features of MS in 58 cases (87.9%), which was superior to ultrasound scan (USS) in the diagnosis of MS and more sensitive to subtle biliary lesions than USS. The overall laparoscopic surgery completion rate was 53.03% (35/66), where the completion rates of MS type I, II and III were 69.05% (29/42), 42.86% (6/14) and zero (0/10), respectively. Thirty-one patients (46.97%) underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients, and 25 of these patients underwent bile duct exploration, repair and T-tube drainage. In addition, 25 patients underwent intraoperative choledochoscopy and T-tube cholangiography. Overall, 21 cases (31.8%) were repaired by simple suturing, and 14 cases (21.2%) were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy. The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time, bleeding volume and cost. Gender, acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach. Age had no effect on the classification of MS, but it influenced the final surgical approach, hospital stay and cost. A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications, and no mortality was observed during the follow-up period of 36.5 ± 26.5 mo (range 13-76, median 22 mo).

CONCLUSION

MRI/MRCP can improve the preoperative diagnosis of MS. The Csendes classification can reflect the difficulty of treatment. The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.

Chronological trends in patients undergoing cholecystectomy in Korea: a nationwide health insurance claims study

Purpose

The incidence of gallstone disease and cholecystectomy is increasing worldwide. The aim of this study was to determine trends in the incidence of cholecystectomy in Korea.

Methods

The National Health Insurance Services database was used to determine patterns in proportion of cholecystectomy and cholecystostomy in the total population of Korea from 2003 to 2017. The age-standardized rate (ASR) was calculated to compare the cholecystectomy and cholecystostomy according to changes in the population structure over time. The ASR was investigated according to patient age, sex, socioeconomic status, use of computed tomography, and type of hospital to identify trends.

Results

The ASR per 100,000 based on the 2010 population of cholecystectomy cases increased markedly from 67.7 to 211.4 between 2003 and 2017. The ASR was consistently higher in female than male (71.9 vs. 63.6 in 2003, 221.8 vs. 201.8 in 2017). Furthermore, the ASR for cholecystectomy increased with age, and surgery for gallstone disease was performed more often at a specialized center than at other medical facilities. The length of hospital stay of cholecystectomy decreased steadily from 10.6 days in 2003 to 6.9 days in 2017.

Conclusion

This study shows that the incidence of cholecystectomy and cholecystostomy has steadily increased over the years in Korea, with a trend toward older age and higher socioeconomic status in patients undergoing cholecystectomy. Increasing use of computed tomography investigations could be a primary cause for this trend. An integrated strategy is needed to manage the increase in older patients undergoing cholecystectomy and shorten their hospital stay with medical safety.

Beyond acute cholecystitis-gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

Gallstone Ileus with COVID-19 Infection: An Unintended Sequela of Non-Operative Management of Acute Cholecystitis During the COVID-19 Pandemic

Appropriate risk stratification and careful follow-up are mandated in elderly patients with comorbidities. Herein, we report a case presenting 5 months after the nonoperative management of acute cholecystitis during the height of the COVID-19 pandemic.

Mirizzi syndrome type V complicated with both cholecystobiliary and cholecystocolic fistula: a case report

Mirizzi syndrome (MS) is a common bile duct (CBD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Patients affected by MS may present abdominal pain and jaundice. A 37-year-old male with neurologic residuals post-encephalitis arrived at the emergency department reporting abdominal pain, jaundice and fever. An ultrasound of the abdomen identified cholecystolithiasis with a dilated CBD. He did not undergo CT or MRI due to poor compliance and parents’ disagreement. Eventually, they accepted to perform endoscopic retrograde cholangiopancreatography, which diagnosed MS with both cholecystobiliary and cholecystocolonic fistula without gallstone ileum (type Va). Therefore, patient underwent cholecystectomy, wedge resection of the colon and choledochoplasty with ‘Kehr's T-tube’ insertion. A plastic biliary stent was successively placed and removed after 4 month. Ultimately, he did neither complain any other biliary symptoms nor alteration in laboratory tests after 4-years of follow-up.

Surgical Management of Gallstone Ileus in Low-Settings Hospital during COVID-19 Outbreak: A Case Report

Introduction  Gallstone ileus is a very infrequent complication of cholelithiasis in which single or multiple stones pass through an abnormal fistula to the lumen of the intestine leading to a true mechanical obstruction. We are reporting a case of a female who developed intestinal obstruction due to gallstones during the coronavirus disease 2019 (COVID-19) outbreak and was managed urgently surgically in a low-settings hospital. Case Presentation  An 85-year-old white female with 40 years history of gallstone disease, hypertension, and type-2 diabetes presented to the accidents and emergency unit with upper central crampy abdominal pain for 5 days associated with green color vomiting and absolute constipation. On examination, she was barely stable, dehydrated, had a distended abdomen, and guarding in the epigastric region. Her electrolytes were disturbed and had elevated serum creatinine and blood urea. Imaging studies confirmed gallstone ileus. Management was surgical despite the lack of facilities and equipment including COVID-19 personal protective equipment. Conclusion  Despite being an infrequent complication, gallstone ileus might present at the most unexpected time and in the least equipped hospital where the surgeon's suspicion, risk stratification, and improvisation by utilizing what is available are the keys for successful management and saving lives.

'Ball valve' small bowel obstruction caused by a large caecal faecolith

Small bowel obstruction is a common surgical presentation, but intestinal faecoliths are rarely reported as a cause. A 75-year-old woman presented with small bowel obstruction from a large faecolith lodged in the caecum. This required removal at laparoscopy-assisted surgery. This case highlights the need to deal promptly with symptomatic intestinal faecoliths as they are unlikely to pass spontaneously and are prone to cause acute obstruction.

A rare case report of an ilio-psoas abscess due to entero-retroperitoneal fistula from gallstones post cholecystectomy

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Ilio-psoas abscess due to gallstone entero-retroperitoneal fistulation post-cholecystectomy has not been reported previously.

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De-novo stone formation in the CBD can occur post-cholecystectomy and can lead to complications.

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Surgeons should consider gallstones as a differential in small bowel fistulation.

Introduction and importance

This is a novel case of a 50-year-old female presenting with several months of left iliac fossa pain, on a background of a cholecystectomy 5 years prior. The aetiology of her pain was an ilio-psoas abscess secondary to an entero-retroperitoneal gallstone fistula, a condition not previously reported in the literature.

Case presentation

CT imaging revealed an abscess superior to the left psoas muscle, with a clear fistula to the small bowel and two calcified stones at the site of the fistula.

The patient was managed operatively, with the fistula disconnected and a 5 cm section of small bowel disconnected.

Clinical discussion

This is a novel case whereby a left sided iliopsoas abscess occurred due to entero-retroperitoneal fistulation of gallstones several years after the patient underwent laparoscopic cholecystectomy. Gallstone fistulation from within the small bowel does not appear to have previously been documented and the exact pathogenesis is unknown.

Conclusion

Gallstones should remain an important, albeit rare, differential diagnosis of small bowel fistulation and abscess formation following cholecystectomy.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Gallstone Ileus: Uncommon Presentation Followed by Less Common Spontaneous Resolution

Gallstone ileus is a rare but significant cause of bowel obstruction. An 82-year-old female was admitted to the hospital with abdominal pain and was initially treated for a possible urinary tract infection. Following a surgical review and based on history, clinical examination as well as radiological findings, a diagnosis of gallstone ileus was made. The patient was prepared for surgery; however, whilst awaiting theatre, she spontaneously passed the obstructing gallstone with full resolution of bowel obstruction symptoms. The usual treatment for gallstone ileus is surgical management with an enterolithotomy; nevertheless, this case highlights the importance of close monitoring and adapting a management plan to fit an evolving clinical scenario.

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome: A case report

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Acute cholecystitis with empyema and Mirizzi Syndrome mimics both XGC and malignancy.

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Subtotal fenestrating cholecystectomy is both safe and effective in these cases.

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PTC can be considered over ERCP for first-line pre-operative biliary drainage.

Introduction

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma.

Presentation of case

A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis.

Discussion

Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient.

Conclusion

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation.

The strategy for Mirizzi syndrome type II with laparoscopic surgery: A case report

INTRODUCTION

Mirizzi syndrome is an unusual condition involving gallstones. Laparotomy is recommended for the treatment of Mirizzi syndrome type II due to the risk of biliary duct injury. We herein report tips for performing laparoscopic surgery for Mirizzi syndrome type II as a treatment option.

PRESENTATION OF CASE

A 72-year-old woman was admitted to our hospital due to abdominal pain and a fever. The diagnosis of Mirrizi syndrome type II was made. Therefore, an endoscopic retrograde biliary drainage tube was placed, and laparoscopic surgery was performed. During the operation, the gallbladder wall was excised at the Hartmann's pouch, and a gallstone was extracted. A fistula between the gallbladder and bile duct was confirmed, and the diagnosis of Mirizzi syndrome type II was made. Partial resection of the gallbladder was performed, and the neck of the gallbladder was sutured. The postoperative course was uneventful.

DISCUSSION

The preoperative diagnosis is important for Mirizzi syndrome, and the combination of various modalities, including endoscopic retrograde cholangiopancreatography, can increase the diagnostic rate. It is often difficult to recognize the anatomy during surgery for Mirizzi syndrome due to severe inflammation. Therefore, it is best to dissect the gallbladder from the bottom, perform excision at the Hartmann's pouch, remove the gallstone and suture the gallbladder wall. Replacement of the biliary tube can aid in recognizing the anatomy and bile duct.

CONCLUSION

Laparoscopic surgery for Mirizzi syndrome is a viable treatment option following an accurate preoperative diagnosis and the recognition of the anatomy during the operation.

Duodenal Obstruction Due to Giant Gallstone: A Case Report

Background

Duodenal obstruction due to a gallstone, also known as Bouveret’s syndrome, is one type of gallstone ileus. This is a rare complication of cholelithiasis. Among gallstone ileus cases, duodenal obstruction is alsorare. Apart from rareness, diagnosis is challenging due to unspecific clinical manifestation. Treatment options have benefits and drawbacks with each as well. Therefore, setting an appropriate option in a certain patient is an important issue.

Case Report

An 85-year-old woman presented clinically with a gastric outlet obstruction. Upper gastrointestinal (GI) endoscopy was attempted but endoscopic exploration was limited because of duodenum filled by fluid. Rigler’s triad was detected on abdominal enhanced CT scan: duodenal obstruction, ectopic gallstone within duodenum lumen, pneumobilia. The stone was very large (9 cm long). The diagnosis was duodenal obstruction due to giant gallstone and cholecysto-duodenum fistula. The patient was treated with a radical one-stage procedure: fistulotomy for gallstone removal, cholecystectomy, side-to-side Roux-en-Y duodenojejunostomy. There were no complications related to surgery during the follow-up period.

Conclusion

Surgery plays an important role in management of duodenal obstruction due to a gallstone, especially a large and impacted stone. Radical one-stage surgery is one of the feasible, safe, and efficient procedures in selected patients.

Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND

Mirizzi syndrome (MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct (CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.

AIM

To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.

METHODS

From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.

RESULTS

Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas (P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis (odds ratio 5.82, P = 0.002; 0.12, P = 0.008, respectively).

CONCLUSION

Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

Laparoscopic Approach for Gallstone Ileus in Geriatric Patients

We report two patients who presented with small bowel obstruction secondary to gallstones in the ileum. Both patients were geriatric women with multiple comorbidities. The first patient was a 73-year-old woman who presented with a gallstone eroding and obstructing the duodenum (Bouveret's syndrome) secondary to gallbladder cancer with diffuse metastatic spread to the liver. The stone was disimpacted endoscopically using lithotripsy. The patient presented two days later after the stone had migrated downstream into the small bowel causing obstruction requiring surgical intervention. Second patient was an 81-year-old woman who presented with small bowel obstruction caused by a gallbladder stone impacted in the distal ileum. Both patients were managed laparoscopically with a mini laparotomy to extract the affected segment of bowel loop via small incision on the anterior abdominal wall at the port site with enterolithotomy. Both patients were discharged by postoperative day four with no complications. We conclude that, in elderly patients with multiple comorbidities presenting with gallstone ileus, laparoscopic approach provides early recovery with minimal pain.

Cecal Perforation by a Large Gallstone: An Unusual Diagnosis

Cholecystocolic fistulas are uncommon, with rare cases of colonic obstruction described in the literature and even rarer cases of intestinal perforation due to gallstones.

We describe a case of a 73-year-old man who presented to our ED with complaints of diffuse abdominal pain, vomiting, constipation, and fever for the past week. Abdomen CT showed signs of acute perforated appendicitis. An exploratory laparotomy was proposed which revealed cecal perforation caused by a 3 cm gallstone. A right colectomy was performed with primary anastomosis, without cholecystectomy or fistula repair. The postoperative period was complicated due to an anastomotic dehiscence on day 12 with the need for a re-laparotomy with an ileotransverse colostomy confection. The patient was in the ICU care for five days and was discharged on the 13th day after the second intervention. 

The clinical presentation of gallstone ileus is nonspecific and vague often leading to a delay in the diagnosis and treatment. CT scan has the best specificity and sensibility for the diagnosis but abdominal X-ray may show the pathognomonic Rigler´s triad. The surgical treatment consists of removing the gallstone with or without simultaneous cholecystectomy and fistula repair.

Reports of colonic perforation due to gallstones are very scarce, which makes this a very low suspicion diagnosis. The ideal surgical approach is not established. The morbidity of these cases can reach 50%.

Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus

Gallstone ileus is a dramatic complication of gallstone disease, uncommon but not exceptional in a busy emergency department. It represents a cause of mechanical intestinal obstruction, which predominantly occurs in elderly and frail patients; this contributes to the high morbidity and mortality rates associated with this condition. The modern radiologist is frequently asked to determine the cause of bowel obstruction and should be aware of the most pictorial features of this unusual disease. Broadly speaking, abdominal radiography and ultrasonography alone are limited in detecting the cause of bowel obstruction, but the sensitivity for the preoperative diagnosis of gallstone ileus may be improved by combining the findings obtained by both techniques. Computed tomography is the modality of choice for the diagnosis of this disease: it may accurately describe the number, size, and location of migrated gallstones and the exact site of bowel obstruction, providing a detailed preoperative planning. Magnetic resonance imaging may be used in selected cases for an exquisite anatomic definition of the fistulous communication.

Pathophysiology, Diagnosis, and Treatment of Colonic Gallstone Ileus in an Elderly Patient

Gallstone ileus is a rare entity, and an obstructing gallstone in the left colon is even less frequent. A 78-year-old man was evaluated for abdominal distension and pain, associated with a lack of bowel movements in the past 5 days. An abdominal computed tomography showed a cholecystocolonic fistula associated with a gallstone in the descending colon. During the operation, the gallstone was retrieved through a longitudinal colotomy proximal to the impaction site, which was then closed.

Bouveret's syndrome and cholecystogastric fistula: a case-report and review of the literature

An exceptionally rare cause of gastric outlet obstruction, Bouveret's syndrome results from proximal impaction of an ectopic gallstone, enabled by fistulization that aberrantly connects the biliary and luminal gastrointestinal tract, typically a cholecystoduodenal fistula. It occurs with a 2:1 female predominance, most often in the eighth decade of life. Endoscopic treatment is the preferred first-line strategy in management, followed by surgical intervention if unsuccessful. Endoscopy failed to retrieve the stone due to its size, despite attempted lithotripsy, which prompted laparoscopic retrieval. Bouveret's syndrome compels a high index of suspicion in proximal gastrointestinal obstruction even when presenting in a male a decade younger than the median age of diagnosis (74 years), with no preceding biliary symptoms particularly as early intervention can considerably reduce morbidity and mortality.

Gallstone Ileus: An Unusual Cause of Intestinal Obstruction

Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal obstruction. Typically as a result of the formation of cholecystoduodenal fistula, surgical removal of the gallstone is the mainstay of treatment in order to relieve the intestinal obstruction. A 34-year-old male with no history of cholelithiasis presented with features of a small bowel obstruction. CT scan of the abdomen demonstrated pneumobilia, a cholecystoduodenal fistula and small bowel obstruction, features suspicious for a gallstone ileus. The patient underwent a laparotomy and removal of two gallstones via an enterotomy. He was discharged home after an uneventful post-operative period. Gallstone ileus is an uncommon cause of mechanical bowel obstruction with often delayed presentation and non-specific symptoms. A high level of suspicion is required in at-risk groups, and in patients presenting with a bowel obstruction and known gallstone disease.