Send reprint requests to: C. E. Anagnostopoulos, M.D., Depart- ment of Surgery,University of ... irregular, ill-defined, tender, firm, immobile mass was localized.
Cholecystopyloric Fistula with Gastric Outlet Obstruction: A Rare Form of Gallstone lleus and its Management MARSHALL E. REDDING, M.D., C. E. ANAGNOSTOPOULOS, M.D., HASTINGS K. WRIGHT, M.D.
I NTESTINAL OBSTRUCTION secondary to gallstones is no longer considered a rare complication of cholelithiasis and cholecystitis. However, the occurrence of a fistulous communicatioin between the gallbladder and pyloric antrum resulting in gastric outlet obstruction by gallstones is indeed rare. In the past, the majority of surgeons reporting on gallstone ileus were of the opinion that no attempt should be made to resect the cholecystoenteric fistula during the initial procedure to relieve acute obstruction. More recently though, after reviewing the large morbidity which attends enterotomy alone, more and more surgeons are advocating aggressive primary approach to the management of gallstone ileus. This paper reports a case of cholecystopyloric fistula with gallstones impacted in the pylorus, gastric antrum and duodenum resulting in gastric outlet obstruction and treated by primary cholecystectomy, closure of the pyloric fistula, Jaboulay gastroduodenostomy and vagotomy. Case Report A 64-year-old woman was admitted to the Yale-New Haven Hospital on May 27, 1969 for further evaluation of recurrent abdominal pain and intractable vomiting. Two years prior to admission, she had been hospitalized in another hospital because of abdominal pain and vomiting and was told that she needed to have her gallbladder removed. Thereafter, she remained asymptomatic until approximately 3 months prior to admission when she again developed upper abdominal pain described as radiating to the back and to the right scapula. Pain was associated with repeated episodes of post-
Submitted for publication October 4, 1971. Send reprint requests to: C. E. Anagnostopoulos, M.D., Department of Surgery, University of Chicago Hospitals, 950 E. 59th Street, Chicago, Illinois 60637.
From the Department of Surgery, Yale University School of Medicine, New Haven, Connecticut prandial vomiting which characteristically afforded relief. There had been an associated 10-pound weight loss. At the time of initial outpatient evaluation, an oral cholecystogram demonstrated retention of dye in the stomach. Subsequent upper gastrointestinal x-ray showed a massively dilated stomach with complete pyloric obstruction (Fig. 1). Pertinent physical findings at the time of her admission to the Yale-New Haven Hospital were limited to the abdomen. An irregular, ill-defined, tender, firm, immobile mass was localized in the epigastrium. The liver was not enlarged and no subcostal tenderness was present. There was no jaundice. Admitting diagnosis was duodenal ulcer with obstruction. Laboratory Data: 39 vol. % Hematocrit 9,500 with 21% eosinophils WBC 200 units Amylase Liver function tests normal Hospital Course: Nasogastric decompression at the time of admission revealed large quantities of retained food and gastric secretions. After 5 days of IV fluids and nasogastric suction, repeat upper gastrointestinal x-rays revealed persistent gastric outlet obstruction. The intragastric filling defect visualized on these films was interpreted as inspissated material around the indwelling N-G tube. With the preoperative diagnosis of obstructing duodenal ulcer, exploratory laparotomy was undertaken on May 5, 1969. The distal antrum, proximal duodenum and omentum were intimately involved in an inflammatory mass along the undersurface of the left lobe of the liver. Initially, the gallbladder was totally obscured. The second and third portions of duodenum were edematous, but were not involved in the inflammatory mass. After identification of the gallbladder and confirming that it represented one wall of the inflammatory mass, cholecystostomy was performed. Several 1-2 cm. stones were present in the gallbladder. Digital exploration from the gallbladder retrograde through the pylorus encountered a 2.5 cm. stone impacted in the pyloric antrum (Fig. 2). Another 2 cm. stone was extracted from the
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211 1% and 3%.1,13,16 The incidence is considerably greater in the population over 65 years of age, reportedly between 23% and 25%.31o0,16 Previous reports concluded that 0.3 to 0.5% of all cases of cholelithiasis ultimately result in gallstone ileus.'9'13 However, with the current trend of more aggressive approach towards asymptomatic gallbladder disease, the incidence is probably declining. The majority of enteroliths secondary to cholecystoenteric fistulae pass spontaneously and among some larger series, the reported frequency of obstruction by enteroliths following fistulization has been as low as 6%.1,13,17 By the time of Cooperman's report4 in 1968 fewer than 800 cases of gallstone ileus had been reported in the literature. Despite the fact that the most frequent site of perforation into the gastrointestinal tract by gallstones is the FIG. 1. X-ray showing massively dilated stomach complete pyloric duodenum, there were only 52 reported cases of duoobstruction. denal bulb obstruction by impacted gallstones at the time of Simonian's report in 1968.15 duodenal bulb. After adequate identification of vital portal strucFar less commonly encountered than small intestine tures, cholecystectomy and fistulectomy were accomplished. Abobstruction by gallstones is gastric or duodenal obstrucsence of choledocholithiasis was confirmed by common duct extion. In 1957, Defeo et al. could find only 31 reported ploration. Transverse closure of the pyloric opening was thought inadequate due to the severe inflammatory response. Hence, it cases of cholecystogastric fistulae.5 After reviewing the was elected to perform a vagotomy and Jaboulay gastroduode- English literature, we can find no more than three addinostomy. Except for a urinary tract infection, the patient had a benign tional cases reported over the past decade. Prior to 1968, postoperative course and remains well more than one year after a total of only ten cases of intragastric gallstones had operation. been documented.4 A subsequent series included three additional cases.4 The rare frequency with which obstructing intragastric stones are encountered is best exDiscussion plained on the high probability of their being expelled 1. Incidence by vomiting. Cholecystoenteric fistula with gallstone ileus represents an unusual, and often unsuspected complication of 2. Management cholelithiasis. The reported incidence of small intestinal Until recent years, surgeons almost uniformly agreed obstruction by gallstones among large series is between that only enterotomy for relief of intestinal obstruction
FIG. 2. Operative photo-
graph and artist's drawing of impacted cholecystopyloric stone.
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REDDING, ANAGNOSTOPOULOS AND WRIGHT
should be attempted during the primary procedure. This principle was undoubtedly a reflection of the prohibitive postoperative mortality associated with the disease in the not too remote past. Raiford 13 in 1961, and Anderson, et al.1 as recently as 1967, reaffirmed this concept. However, more recent authors, having reviewed the immediate and long-term complications attending enterotomy alone, have advocated a more aggressive initial approach which includes cholecystectomy and fistula repair in conjunction with enterotomy for obstruction. This concept is not a new one, for in 1922, Pybus 12 resected a cholecystoduodenal fistula and performed cholecystostomy during ileotomy for obstructing gallstones (a catastrophe resulting from recurrent gallstone ileus in an earlier case had prompted this more aggressive approach). Holz,8 in 1929, inadvertently entered a cholecystoduodenal fistula while attempting to extract an impacted duodenal stone. While forced to close the fistula, he elected to remove the gallbladder. Despite the feasibility of the approach, the lack of its acceptance is best illustrated by the fact that in 1967 when Cooperman4 reported the largest individual series (eight patients) treated by primary cholecystectomy, the total number of reported cases was no more than ten.2'7'11" 8'19 (Other reported cases of primary resection for gallstone ileus prior to that time were not done electively). -Reviewing the English literature since 1968, we can find only one additional report of successful fistula resection and cholecystectomy.14 Several excellent articles appearing over the past decade consider in detail the subject of primary versus staged resection of cholecystoenteric fistula with gallstone ileus."2'4""'8 More recent data would indicate that with proper patient selection and preoperative preparation, one stage cholecystectomy and enterolithotomy for gallstone ileus is not attended by a significantly higher mortality than is enterotomy alone, even when considered in light of the fact that there has been a progressive decline in mortality following enterotomy only over the past several decades. In the largest reported series of elective one stage resections, the operative mortality was 13% (one death in eight patients); the author quoted the mortality following enterotomy as 13%.4 Further case reports are needed to substantiate the validity of this appealing principle which offers the benefit of dealing with the entire disease process during one operative procedure, and thus eliminating the high morbidity known to follow enterotomy alone.
Ann. Surg. * Aug. 1972
Summary A rare case of cholecystopyloric fistula associated with intragastric and duodenal gallstones resulting in gastric outlet obstruction is presented. The patient was successfully managed throtugh one-stage cholecystectomy and relief of obstruction by Jaboulay gastroduodenostomy and vagotomy. References 1. Anderson, R. E., Woodward, N., Diffenbaugh, W. S. and Strohl, E. L.: Gallstone Obstruction of the Intestine. Surg. Gynecol. Obstet., 125:540, 1967. 2. Berliner, S. C. and Burson, L. C.: One Stage Repair for
Cholecystoduodenal Fistula and Gallstone Ileus. Arch. Surg., 90:313, 1965. 3. Brockis, J. G. and Gilbert, M. C.: Intestinal Obstruction by Gallstones: A Reviev of 179 Cases. Brit. J. Surg., 44:461, 1957. 4. Cooperman, A. M., Dickerson, E. R. and Remine, WV. H.: Changing Concepts in the Surgical Treatment of Gallstone Ileus. Ann. Surg., 167:383, 1968. 5. Defeo, E. and Meigher, S. C.: Gallstones Impacted in the Stomach and Duodenal Bulb Demonstrated by Roentgenologic Examination. Am. J. Roentgenol., 77:40, 1957. 6. Foss, H. L. and Summers, J. D.: Intestinal Obstruction from Gallstones. Ann. Surg., 115:721, 1942. 7. Frazer, W. J.: Intestinal Obstruction by Gallstones. Brit. J. Surg., 42:210, 1954. 8. Holz, E. B.: Zur frage des Gallensteinileus. Arch. F. Klin Chir., 155:166, 1929. 9. Mayo, C. W. and Brown, P. W.: Intestinal Obstruction Caused by Gallstones. Surgery, 25:924, 1949. 10. Moore, T. C. and Baker, W. H.: Operative and Radiologic Relief of Gallstone Intestinal Obstruction. Surg. Gynecol. Obstet., 116:189, 1963. 11. Morlock, C. G., Shockett, E. and Remine, W. H.: Intestinal Obstruction due to Gallstones. Gastroenterology, 30:462, 1956. 12. Pybus, F. C.: Note on Two Cases of Gallstone Ileus. Lancet, 2:812, 1922. 13. Raiford, T. S.: Intestinal Obstruction due to Gallstones. Ann. Surg., 153:830, 1961. 14. Shartsis, J. M. and Dinan, J. T., Jr.: Benign Cholecystogastroduodenocolic Fistula. Am. J. Dig. Dis., 14:424, 1969. 15. Simonian, S. J.: Gallstone Obstruction of the Duodenal Bulb. Lancet, 1:893, 1968. 16. Vick, R. M.: Statistics of Acute Intestinal Obstruction. Brit. Med. J., 2:546, 1932. 17. WVakefield, E. G., Vickers, P. M. and Walter, W.: Intestinal Obstruction Caused by Gallstones. Surgery, 5:670, 1939. 18. Warshaw, A. L. and Bartlett, M. K.: Choice of Operation for Gallstone Intestinal Obstruction. Ann. Surg., 164:1051, 1966. 19. Welch, J. S., Huizenga, K. A. and Roberts, S. E.: Recurrent Intestinal Obstruction due to Gallstones. Proc. Staff Meet. Mayo Clin., 32:628, 1957.
