EGS P27 Twice Recurrent Gallstone Ileus Requiring 3 Laparotomies – A Case Report

Abstract

Abstract Background Gallstone ileus is a well-known and not an uncommon complication of gall stone disease, with standard management being an enterotomy and extraction of the obstructing gallstone with management of the gallbladder and the billio-enteric fistula being deferred to an interval procedure if indicated. Recurrent gallstone ileus are not unheard of, but are quite rare and are the reason cited by the proponents of a single stage procedure. While a single stage procedure is possible - involving an enterotomy as well as a challenging cholecystectomy and the management and closure of a duodenal fistula – more commonly than not it is not performed. Methods Twice recurrent gallstone ileus is extremely rare and on performing a literature review only 1 published case report has been identified. Here we present the case of an 87-year-old Caucasian female, presenting with 3 incidences of gall stone ileus in a 30 day period requiring 3 laparotomies. Initial presentation to our institution was in November 2022 with a CT proven localised Gallbladder perforation. The first presentation with gallstone ileus was on 21/03/2023 with symptoms of bowel obstruction and CT proven obstructing 23mm gallstone 8 cm from the ileocaecal valve as well as pneumobillia and two other stones in the gallbladder. Results The index laparotomy was performed and no transition point was found, and bowel run-through from DJ to ICV revealed no intraluminal gall stones and the caecum was full of fluid. The gallstone had passed into the colon spontaneously and no enterotomy was performed. Two subsequent laparotomies were required due to CT proven incidence of recurrent Gallstone ileus on 30/03/2023 and 20/4/2023, were enterotomies were performed and the obstructing stones extracted each time. An informed decision not to tackle the gallbladder and the duodenal fistula was taken by a consensus of 3 consultant surgeons due to the frailty of our patient. Conclusions Our patient made a meaningful recovery after developing an entero-cutaneous fistula that resolved with conservative management and was discharged home on 15/05/2023. While our patient's frailty and previous gallbladder perforation made the decision not proceed with a cholecystectomy and repair of the duodenal fistula a straightforward one, the incidence of twice recurrent gallstone ileus in the span of a month raises questions as to whether other techniques should be considered in a more fit patient such as a single stage operation or a Cholecystolithotomy.