Laparoscopic Approach for Gallstone Ileus in Geriatric Patients

Abstract

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.

Laparoscopic management of gallstone ileus: A case report and literature review

“…The GI is secondary at the migration of a gallstone to the bowel through a fistula [7] , [9] , [10] , [13] , formed due a chronic inflammation in the gallbladder and the local pressure by the gallstone against, most frequently, the small bowel [8] , [9] , [13] . The cholecytoduodenal fistula is the most common, in 85% of the cases, followed by cholecystogastric, cholecystojejunal and cholecystocolonic [1] , [3] , [5] , [12] , [13] , [14] .…”

“…The diagnosis of GI is difficult, with a 43–73% made preoperative, and a median between admission and surgical intervention of 2–37 days, becoming an independent prognostic factor to the high mortality of this disease (7–30%) [3] , [5] , [7] , [9] , [12] , [13] . This is explained because the nonspecific presentation, lack of clear history of previous biliary disease and the typical radiological features being overlooked, if they are not supported by a clinical suspicion [2] , [5] , [10] , [12] .…”

“…Patients with GI usually presents with SBO symptoms and 40–50% have history of recent episodes of biliary colic, jaundice or acute cholecystitis. On physical examination, the patient may be acutely ill and often dehydrated, jaundice could also be part of the findings; fever, toxicity and signs of peritonitis can be found in advance stage of the disease [1] , [3] , [4] , [9] , [12] , [13] , [14] . Classically Mordor triad is described as gallstone history, signs of cholecystitis and sudden onset of SBO.…”

“…It can show pneumobilia, signs of SBO, anatomic site affected and intestinal intraluminal gallstone. For GI has sensitivity of 90–93% and specificity of 100%, also helping in planning further management [1] , [2] , [3] , [4] , [7] , [9] , [13] , [14] . With CT Rigler's triad is found in 78% of cases [9] .…”

“…It occurs when a gallstone becomes lodged between the gallbladder and the bowel, forming a cholecysto-enteric fistula, with impaction of the gallstones at different levels of the gastrointestinal tract [1] , [2] , [3] , [4] , [6] , [7] , [8] , [9] , [10] , [11] .…”