Challenges of elderly patients with short bowel syndrome

Objective: This is a case report presenting two elderly patients; one with mesenteric ischemia and the second with gallstone ileus, in which their operative management has resulted in short bowel syndrome (SBS). Case: This pathology required prolonged post-operative care and monitoring with the management of different related complications. Conclusion: This case report will cover the pathophysiology, medical and operative management in addition to the acute and chronic complications of SBS

The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Cholecystoduodenal Fistula

Large gallstones could erode through gallbladder wall to nearby structures, causing fistulas, gastric outlet obstruction and gallstone ileus. They typically occur in elderly patients with comorbidities carrying therapeutic challenges. We present a case of a middle-aged woman who was thought to have symptomatic cholelithiasis. Extensive adhesions precluded safe cholecystectomy. While hepatobiliary iminodiacetic acid scan and magnetic resonance imaging with cholangiopancreatography (MRI-MRCP) failed to visualize the gallbladder, computed tomography (CT) was consistent with cholecystoduodenal fistula. A very large gallstone was seen endoscopically in the duodenum, which was broken down into pieces using a large stiff snare.

The Regularity of the Site of Impaction in Recurrent Gallstone Ileus: A Systematic Review and Meta-Analysis of Reported Cases

Objective. Due to the rarity of recurrent gallstone ileus (RGSI), its epidemiological and clinical features are elusive. With a focus on mortality and the site of impaction, this study consolidates the key clinical characteristics of index GSI (IGSI) and RGSI. Methods. A meta-analysis of cases reported on RGSI was performed. Risk factors for mortality and site of impaction were examined, and a subgroup analysis was performed for age, sex, and site of impaction (jejunum, ileum, or others). Results. In the final analysis, 50 (56 individual cases) studies were included. The paired data for the site of impaction was available for 45 patients. Women accounted for 87.3% of all RGSI cases included in the pooled analysis. The median age (interquartile range, IQR) of the patients was 70 (63–76) years, and the median time of recurrence (IQR) was 20.5 (8.5–95.5) days. The overall mortality rate was 11.8%, without correlation between the mortality rate and age, the time of recurrence, or the site of impaction. The region in which the stone was found in RGSI and IGSI was similar in most cases p = 0.002 . Logistic regression also revealed a higher probability of stone impaction in the ileum in RGSI if it was the site of impaction in IGSI. In most cases, enterolithotomy was the preferred method. Conclusions. A high index of suspicion for RGSI should be maintained for older women with a history of GSI. The region where the stone was impacted during IGSI should be investigated first in such patients.

P-EGS02 Impact of delayed elective laparoscopic cholecystectomy on incidence and complications from gallstone ileus

Background The negative impact of the COVID-19 pandemic on the provision of elective surgery in the UK has been profound. Per the latest National figures, a total of 4.59 million patients are awaiting an elective operation (1). In our Trust, emergency operations and cancer service took precedence as we worked to minimize risks of COVID-19 while providing life-saving procedures. Subsequently, our ‘hot gallbladder’ operating list was put on hold for a period of 18 months. In our Trust, the current waiting time for an elective laparoscopic cholecystectomy is 52 weeks for symptomatic gallstone disease. Gallstone ileus is a well-recognized but rare complication of gallstones (2) and needs operative treatment. We performed this study to investigate the impact of delayed cholecystectomy on the incidence of gallstone ileus and the morbidity and mortality associated with this. Methods Retrospective study reviewing all acute admissions with gallstone ileus for 4 years from 2016 to 2020. Total number of patients was 19. Data collated from patient’s notes to include demographics and co-morbidities, operative notes, theatre records, and WebICE. Results Demographically, there was significant female preponderance (M : F : 1 : 18). Mean age of patients was 76.7 years. 17/19 patients underwent laparotomy as the primary operation (89%) and 1 (5%) had a laparoscopic procedure. 1 patient (5%) was managed conservatively. All patients had a CT scan as pre-operative imaging. 7 (34%) also had USS and 4 (20%) had MRCP. Mean length of stay in hospital was 13 days. 3 (15%) patients required re-admission to hospital for surgical and medical complications within 30 days. 3 (15%) patients returned to theatre for a second laparotomy within the index admission for recurrence of gallstone ileus. 8 (40%) patients had post-operative complications. There were 2 (10%) mortalities. 9 (45%) patients had gallstone related complications preceding their index presentation; majority (66%) which was calculous cholecystitis. The mean time between diagnosis of gallstone disease and emergency laparotomy for gallstone ileus was 38 months. Conclusions Gallstone ileus can be a life-threatening complication of gallstone disease and needs prompt recognition and treatment. Patients with known gallstones with symptoms of bowel obstruction should have a CT scan at time of presentation. Surgery is the mainstay treatment following resuscitation and concurrent conservative management. Early elective laparoscopic cholecystectomy can prevent mortality and morbidity from emergency laparotomy for gallstone ileus.