Gallstone ileus: One-stage surgery in a patient with intermittent obstruction

Gallstone ileus, an uncommon complication of cholelithiasis, is described as a mechanical intestinal obstruction due to impaction of one or more large gallstones within the gastrointestinal tract. The clinical presentation is variable, depending on the site of obstruction, manifested as acute, intermittent or chronic episodes. A 51-year-old female patient was referred to our hospital with 3 events of intestinal obstruction during the previous 7 d. At admission, there were clinical signs of intestinal obstruction; abdominal film demonstrated dilated bowel loops, air-fluid levels and a vague image of a stone in the inferior left quadrant. Once stabilized, a laparotomy was performed. Surgical findings were distention of the jejunum and ileum proximal to a palpable stone in the ileum as well as gallstones and a cholecystoduodenal fistula in the gallbladder. An enterolithotomy, repair of the cholecystoduodenal fistula and cholecystectomy were performed. The postoperative course was uneventful. There is no uniform surgical procedure for this disease. When the patient is too ill or when biliary surgery is not advisable, an enterolithotomy is the best option. The one-stage procedure should be the offered to adequately stabilized patients when local and general conditions, such as good cardiorespiratory and metabolic reserve permit a more prolonged surgical procedure.     

Gallstone ileus presenting as intussusception: A case report

BackgroundGallstone ileus is a complication of acute cholecystitis that accounts for 25% of bowel obstruction cases in the elderly. To our knowledge, only one other case of gallstone ileus presenting as intussusception has been reported in the literature, and involved non-operative management with an unfavorable outcome.Case presentationHere we report the case of 69 year old woman presenting with symptoms of acute small bowel obstruction with a surgical history significant for cholecystectomy 30 years prior. Computed tomographic imaging showed a target sign in the small bowel consistent with intussusception, but intraoperative diagnosis revealed this to be a gallstone. A simple enterolithotomy was conducted and the patient has since been symptom free.DiscussionGallstone ileus has a high mortality rate (12–17%) and is an important differential diagnosis to consider, especially as the elderly population throughout the world continues to grow.ConclusionAs radiographic features of gallstones are variable we suggest maintaining a high index of suspicion for gallstone ileus in any elderly patient presenting with SBO, even with a seemingly contradictory surgical history.     

Anesthetic considerations for laparoscopy for rectal cancer in patient with amyotrophic lateral sclerosis: A case report

Amyotrophic lateral sclerosis, which is also known as motor neuron disease, is a chronic neurodegenerative disease characterized by progressive muscular weakness, respiratory muscle disability, and eventual death. Previous epidemiologic studies have shown no association between cancer and amyotrophic lateral sclerosis. Colorectal cancer arising in patients with amyotrophic lateral sclerosis has rarely been reported. Here, we report a case involving rectal cancer arising in a patient with amyotrophic lateral sclerosis who subsequently underwent curative laparoscopic surgery and adjuvant chemotherapy. Amyotrophic lateral sclerosis causes the deterioration of respiratory function by compromising expiratory and inspiratory muscles; accordingly, patients with amyotrophic lateral sclerosis are at high anesthetic risk, especially with respect to general anesthesia. Careful airway management is essential, and intraoperative neuromuscular monitoring is important. A depolarizing muscle relaxant such as succinylcholine should not be used because of the potential risk of developing hyperkalemia or rhabdomyolysis. Thus, a nondepolarizing muscle relaxant (rocuronium) was used at a low dose in this case. In addition, fentanyl for postoperative patient-controlled analgesia should be used cautiously because fentanyl can cause respiratory muscle rigidity, which may reduce postoperative respiratory function in patients with amyotrophic lateral sclerosis.     

A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy

INTRODUCTIONGallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported.PRESENTATION OF CASEWe report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy.DISCUSSIONLaparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract.CONCLUSIONEndoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery.     

Total intravenous anesthesia without muscle relaxant in a patient with amyotrophic lateral sclerosis

A 63-year-old woman with amyotrophic lateral sclerosis (ALS) was scheduled for open reduction and internal fixation of the right tibia. Total intravenous anesthesia using propofol and remifentanil without muscle relaxant was selected as the anesthetic method, in order to avoid the possible occurrence of ventilatory depression due to abnormal responses to muscle relaxants and exacerbation of the motor neuron disease. After standard and neuromuscular monitoring devices were applied, anesthesia was induced and maintained with target controlled infusion of propofol and remifentanil in the range of 2.5–5.0 μg·ml⁻¹ and 2.5–5.0 ng·ml⁻¹, respectively. To avoid delayed neuromuscular recovery, we did not use any muscle relaxant at all. Intubation was successful and there were no remarkable events during anesthesia, except for three brief hypotensive events; there was no exacerbation of ALS itself during or after the anesthesia. She was discharged on postoperative day 3, without any discomfort.     

Case report - Bouveret’s syndrome with pancreatitis: A rare combination

Introduction and importanceBouveret’s syndrome is characterised by gastric outlet obstruction due to impaction of gallstone in the duodenum through a cholecystoduodenal fistula, having concurrent pancreatitis makes it an even rarer presentation.Case presentationWe present an 82-year-old woman who presented with acute pancreatitis which she described 2 days of right upper quadrant pain with nausea and vomiting. Biliary obstruction signs were not present. She was known to have cholelithiasis but was for non-operative management due to significant cardiac history and multiple comorbilities.Clinical findings and investigationsOn initial examination, abdomen was soft with mild right upper quadrant tenderness. Murphy sign was negative. Lipase level was raised at 64,261U/L with cholestasis appearance on liver function test. Bouveret’s syndrome was later diagnosed on CT after symptoms of gastric outlet obstruction surfaced during her admission.Interventions and outcomeAn on-table endoscopic stone retrieval was done as first-line treatment. After multiple attempts of stone retrieval via endoscopy, surgical extraction of the impacted gallstone was required. Patient’s post-operative care was further challenged by effects from pancreatitis. Patient eventually recovered well and was discharged from hospital.Relevance and impactWhen managing patients with gallstone pancreatitis, presence of persistent vomiting should raise suspicion of Bouveret’s syndrome. Bouveret’s syndrome can be diagnosed in these patients with aid of CT imaging or endoscopy. Stone extraction is required to treat Bouveret’s syndrome, endoscopic retrieval is first-line therapy as surgery has mortality risk of 12–30%. Prolonged recovery period can be expected due to concurrent inflammatory effects from acute pancreatitis.     

Bowel obstruction and perforation due to a large gallstone. A case report

IntroductionGallstone bowel obstruction is a rare form of mechanical ileus usually presenting in elderly patients, and is associated with chronic or acute cholecystitis episodes.Case presentationWe present the case of an 80 year old female with abdominal pain, inability to defecate and recurrent episodes of diarrhea for the past 8 months. CT examination uncovered a cholecystoduodenal fistula along with gas in the gall bladder and the presence of a ≥2 cm gallstone inside the small bowel lumen causing obstruction. Patient was admitted to the operating room, where a 3.2 cm gallstone was located in the terminal ileus. A rupture was found in the antimesenteric part of a discolored small bowel segment, approximately 60 cm from the ileocaecal valve, through which the gallstone was recovered. The bowel regained its peristalsis, and the rupture was debrided and sutured. Patient was discharged uneventfully on the 6th postoperative day.DiscussionGallstone ileus is caused due to the impaction of a gallstone inside the bowel lumen. It usually passes through a fistula connecting the gallstone with the gastrointestinal tract. It can present with nonspecific or acute abdominal symptoms. CT usually confirms the diagnosis, while there are a number of treatment options; conservative, minimal invasive and surgical. Our patient was successfully relieved of the obstruction through recovery of the gallstone using open surgery, with no repair of the fistula.ConclussionAlthough rare, gallstones must be suspected as a possible cause of bowel obstruction, especially in elderly patients reporting biliary symptoms.     

Foramen magnum meningioma presenting as amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a progressive, degenerative disease of the nervous system. It affects adults in all age groups and leads to death few years after the diagnosis. The etiology is unknown, and there no convincing medical or surgical therapy. Some diseases can mimic ALS. If diagnosed early these may be treatable, but if misdiagnosed as ALS and left untreated they may be fatal. We present a case of foramen magnum meningioma presenting clinically as ALS. After surgery, the symptoms disappeared and the neurological deficits improved.     

Effects of lumbar sympathetic ganglion block for a patient with amyotrophic lateral sclerosis (ALS)

A 59-year-old man with amyotrophic lateral sclerosis (ALS) received lumbar epidural and sympathetic ganglion blocks to increase regional blood flow and improve his clinical symptoms. After a lumbar epidural block (0.5% mepivacaine), the skin temperature of his affected lower extremities rose by 7.0°C and became close to that of the intact side, and the distance he was able to walk with his cane increased from 2 to 8 m. The clinical effects produced by the lumbar sympathetic ganglion block (99.5% alcohol) were sustained for approximately 8 weeks after the first block and for approximately 6 weeks after the second block. There were no particular adverse effects or complications associated with these nerve block procedures. Epidural and sympathetic ganglion blocks for an ALS patient, albeit their effects are of a transient nature, may improve related clinical symptoms, and were thought to play a contributory role in improving our patient's quality of life.     

米诺环素联合美金刚治疗肌萎缩性脊髓侧索硬化病

目的 观察联合美金刚和米诺环素用药在肌萎缩性脊髓侧索硬化病(ALS)转基因小鼠模型治疗中的协同作用.方法 ALS转基因小鼠被随机分成生理盐水对照组、米诺环素组、美金刚组和米诺环素/美金刚组.对腹腔注射米诺环素和美金刚后ALS小鼠的运动能力、发病时间、生存时间以及腓肠肌重量变化进行定量分析.结果 (1)与对照组发病时间(98.3±4.6)d比较,米诺环素组和美金刚组分别为(117.1 ±7.4)、(114.0±3.5) d(P ＜0.05)；对照组生存期为(129.4±6.2)d,米诺环素组和美金刚组分别为(146.2±5.9)、(141.9±6.3) d(P ＜0.05).联合治疗组发病时间和生存期分别为(126.2±8.4)d和(159.1±3.9)d.与对照组比较,米诺环素组、美金刚组和联合治疗组生存时间分别延长13％、11％和23％.(2)对照组小鼠第16周时腓肠肌重量为(83.5±10.2)mg,米诺环素组和美金刚组分别为(133.7 ±12.5)、(130.1 ±10.3) mg,联合治疗组为(186.3±17.9) mg,与对照组和单一用药组比较,差异有统计学意义(P＜0.05).结论 联合米诺环素和美金刚对治疗ALS小鼠具有协同治疗作用.     

Gallstone ileus associated with impaction at Meckel’s diverticulum: Case report and literature review

Gallstone ileus due to erosion of one or more gallstones into the gastrointestinal tract is an uncommon cause of small bowel obstruction. The site of impaction is usually distal ileum, and less commonly the jejunum, colon, duodenum, or stomach. We report a rare case of gallstone ileus with impaction at the proximal small bowel and at a Meckel’s diverticulum (MD) in a 64-year-old woman managed with laparoscopic converted to open small bowel resections. Patient was discharged home in stable condition and remained asymptomatic at 6-mo follow up. We review the current literature on surgical approaches to MD and gallstone ileus. Diverticulectomy or segmental resection is preferred for complicated MD. For gallstone ileus, simple enterolithotomy or segmental resection are the most the most favored especially in older co-morbid patients due to lower mortality rates and the rarity of recurrent gallstone ileus. In addition, laparoscopy has been increasingly reported as a safe approach to manage gallstone ileus.     

Undiagnosed amyotrophic lateral sclerosis and respiratory failure

Two patients suffering from exacerbation of chronic respiratory insufficiency due to previously undiagnosed amyotrophic lateral sclerosis are reported. Both patients had a false diagnosis of asthma with a restrictive component. The diagnosis had been made after pulmonary function studies, and both patients had also treatment for asthma. A central etiology was suspected when weaning from mechanical ventilation proved unsuccessful during respiratory failure, necessitating intensive care. A neurologic examination and a typical electroneuromyography recording confirmed the diagnosis of amyotrophic lateral sclerosis. Neuromuscular disorders must be excluded when treating patients with respiratory failure, even if they already have the diagnosis of chronic pulmonary disease.     

Management and outcome of recurrent gallstone ileus: A systematic review

AIM: To help the surgeon in decision making when treating a patient with recurrent gallstone ileus (RGSI).METHODS: A systematic review related to RGSI was performed using the databases CINAHL, EMBASE, MEDLINE via PubMed from May 1912 to April 2015. All languages were included and the grey literature was also searched. The abstracts were explored for relevance to the topic and full texts obtained as appropriate. A manual search was carried out by scrutinising the reference lists of all the full text articles and further articles were identified and obtained. Total of 903 articles were identified, 656 were excluded after abstract review, 247 full text articles were reviewed and 91 articles selected for final analysis. There were 113 cases of RGSI.RESULTS: There were 113 cases of RGSI reported in 91 articles. The majority of the recurrences, 62.6%, occurred within 6 wk of the index event. The male to female ratio was 1:7. The mean age was 69.6 years (SD 11.2) with a range of 38-95 years. The small bowel was the commonest site of impaction (92.2%). Treatment data was available for 104 patients. The two main operations performed were: (1) Enterolithotomy without repair of biliary fistula in 70.1% of all patients with a procedural mortality rate of 16.4% (12/73) and (2) a single stage surgery approach involving enterolithotomy with cholecystectomy and repair of the biliary enteric fistula in 16.3% with a procedural mortality of 11.7% (2/17). A subset analysis over last 25 years showed mortality from eneterolithotomy was 4.8% while single stage mortality was 22.2%. Enterolithotomy alone was the commonest operation performed for RGSI with four patients (5.4%) having a further recurrence of gallstone ileus.CONCLUSION: Enterolithotomy alone or followed by a delayed two-stage treatment approach is the preferred choice offering low mortality and reduced risk of recurrence.     

Final analysis of the pilot trial of diaphragm pacing in amyotrophic lateral sclerosis with long-term follow-up: diaphragm pacing positively affects diaphragm respiration

Background

Respiratory insufficiency is the major cause of mortality in patients with amyotrophic lateral sclerosis or Lou Gehrig’s disease. This is the final report of the diaphragm pacing (DP) pilot trial.

Methods

Patients underwent laparoscopic diaphragm electrode implantations and subsequent conditioning of diaphragms. Serial respiratory function tests were performed in the initial year and followed until death.

Results

Sixteen patients were implanted with no perioperative or unanticipated device-related adverse events. There were 452 implant-months of follow-up. DP allowed greater movement of the diaphragm under fluoroscopy, increased muscle thickness, and decreased the decline in forced vital capacity. Median survival from implant was 19.7 months with the cause of death respiratory in only 31%.

Conclusions

Long-term analysis of DP in amyotrophic lateral sclerosis showed no safety issues and can positively influence diaphragm physiology and survival. This formed the initial basis for subsequent US Food and Drug Administration approval.     

Complete worldwide operative experience in laparoscopic diaphragm pacing: results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients

Background  Diaphragm movement is essential for adequate ventilation, and when the diaphragm is adversely affected patients face lifelong positive-pressure mechanical ventilation or death. This report summarizes the complete worldwide multicenter experience with diaphragm pacing stimulation (DPS) to maintain and provide diaphragm function in ventilator-dependent spinal cord injury (SCI) patients and respiratory-compromised patients with amyotrophic lateral sclerosis (ALS). It will highlight the surgical experiences and the differences in diaphragm function in these two groups of patients. Methods  In prospective Food and Drug Administration (FDA) trials, patients underwent laparoscopic diaphragm motor point mapping with intramuscular electrode implantation. Stimulation of the electrodes ensued to condition and strengthen the diaphragm. Results   From March of 2000 to September of 2007, a total of 88 patients (50 SCI and 38 ALS) were implanted with DPS at five sites. Patient age ranged from 18 to 74 years. Time from SCI to implantation ranged from 3 months to 27 years. In 87 patients the diaphragm motor point was mapped with successful implantation of electrodes with the only failure the second SCI patient who had a false-positive phrenic nerve study. Patients with ALS had much weaker diaphragms identified surgically, requiring trains of stimulation during mapping to identify the motor point at times. There was no perioperative mortality even in ALS patients with forced vital capacity (FVC) below 50% predicted. There was no cardiac involvement from diaphragm pacing even when analyzed in ten patients who had pre-existing cardiac pacemakers. No infections occurred even with simultaneous gastrostomy tube placements for ALS patients. In the SCI patients 96% were able to use DPS to provide ventilation replacing their mechanical ventilators and in the ALS studies patients have been able to delay the need for mechanical ventilation up to 24 months. Conclusion   This multicenter experience has shown that laparoscopic diaphragm motor point mapping, electrode implantation, and pacing can be safely performed both in SCI and in ALS. In SCI patients it allows freedom from ventilator and in ALS patients it delays the need for ventilators, increasing survival. Presented as an oral presentation at the Plenary Session of SAGES 2008 Scientific Session, Philadephia.     

Enterohepatic fistula in a Crohn’s disease patient: A case report

IntroductionFistulous tracts are a hallmark of Crohn’s Disease. However, solid organ to intestinal fistulas are rare with previously few case reports of colosplenic fistulas and one case report of an enterohepatic fistula.Presentation of caseWe review the available literature and present the first case report of an enterohepatic fistula in a female with Crohn’s Disease to be treated operatively. The patient did well postoperatively with complete resolution of her fistula.DiscussionCrohn’s Disease is an inflammatory bowel disease that can present with fistulas. However, a fistula between the liver and bowel is exceedingly rare with only one previous case report. This is the first report of an enteroheptic fistula that has been managed successfully with an operation.ConclusionNot all enteroenteric fistulas are apparent preoperatively. When discovered, laparoscopic enterohepatic fistula takedown is feasible for this rare disease process manifestation.     

Anesthetic management of laparotomy for a patient with amyotrophic lateral sclerosis: a case report

Amyotrophic lateral sclerosis (ALS) is a disease involving motor neurons. There are two major problems in anesthetic management for patients with motor neuron diseases; prolongation of the effect of non-depolarizing muscle relaxant, and controversy about a use of neuraxial block. We describe the anesthetic management of laparotomy for a patient with ALS by general anesthesia alone. A 55-year-old man, suffering from ALS, was scheduled for hemicolectomy and colostomy. General anesthesia was induced by intravenous administration of ketamine, thiopental and fentanyl. After manual ventilation using sevoflurane (5% in oxygen) for 15 minutes, the trachea was intubated without using a non-depolarizing muscle relaxant. General anesthesia was maintained by sevoflurane, nitrous oxide and fentanyl. Since muscle relaxation required for tracheal intubation and surgical procedure was obtained sufficiently using sevoflurane, a non-depolarizing muscle relaxant was not necessary throughout the anesthetic management. The patient emerged from general anesthesia smoothly, and was extubated without any complications. For the postoperative pain management, we administered opioids intravenously, providing good analgesia. The postoperative course was uneventful, and there was no exacerbation of neurological signs and symptoms of ALS.     

Thoracoscopic treatment of a broncho-esophageal fistula: A case report

IntroductionBroncho-esophageal fistula is a rare clinical condition which can be manifested with non-specific signs and symptoms.Presentation of a caseHere, we report an adult case of a broncho-esophageal fistula in a 43-year-old man referred for chronic cough after fluid food intake and weight loss. Barium swallow, esophagogastroduodenoscopy, bronchoscopy and Computed Tomography of the chest demonstrated a broncho-esophageal fistula between the apical segmental bronchus of the lower right lobe and the middle section of the esophagus. The patient underwent video-assisted thoracoscopic surgery for resection of the fistula. No post-operative complications occurred.DiscussionBroncho-esophageal fistula in adults is rare and its diagnosis is often delayed due to the frequent lack of specific symptoms. Although there is no standard protocol, the most widely used treatment is thoracotomy with identification and dissection of the fistula tract followed by repair of bronchial and esophageal defects.ConclusionsVideo-assisted thoracoscopic surgery appears to be an effective and minimally invasive approach for the treatment of broncho-esophageal fistulas, especially in young, healthy subjects.