The Unusual Complications of Ordinary Gallstones

A cholecystectomy is generally an uncomplicated procedure, but on the rare occasions when gallstones migrate to adjacent viscera or vascular structures, it becomes a considerably more complicated operation.

The April 2014 issue of Surgical Clinics of North America included a comprehensive review of complicated cholecystectomies by surgeons at Rush University Medical Center in Chicago. They began by describing how extrinsic bile duct compression resulting from gallstones can cause Mirizzi syndrome in 0.2-1.5% of patients. This condition necessitates biliary-enteric reconstruction and is best managed at an institution with experience in the procedure.

Focusing primarily on other fistula formations, the paper found:

• Occasionally, patients with chronic or neglected gallstones develop biliary-enteric fistulas and subsequent intestinal obstruction. These fistulas are often symptomless or associated with vague symptoms like indigestion until an acute episode presents as fever, chills, and abdominal pain. Surgeons will need to relieve the obstruction and repair any obvious damage.
• Hemobilia is a form of biliary-vascular fistula in which the patient hemorrhages into the biliary system, usually periodically. The bleeding is typically occult but it can be massive and is often precipitated by trauma. It is a pseudoaneurysm that is preferentially controlled by selective arterial embolization.
• Bilhemia, or direct bile flow through a biliary-vascular fistula, is rare and usually forewarned by rapidly increasing jaundice with relatively normal liver enzymes.
• Thoracobiliary fistulas usually empty into the pleural space or the bronchial tree. In Western countries, subhepatic abscesses or postoperative bile duct stenosis leading to gallbladder perforation are the most frequent causes. Surgeons tend to treat thoracobiliary fistulas with percutaneous and endoscopic interventions.

Lastly, the authors addressed lost gallstones, a frequent occurrence during laparoscopic cholecystectomy that can lead to numerous issues. Using a flow chart, they described the many potential septic, biliary, and fistula complications related to stone spillage.

Since many of the conditions described in the review are rare, the researchers said it might help astute surgeons recognize obstacles as they arise.