Late (21 years) Complications of Temporary Cholecystostomy in a Disease-Free (Acalculous) Gallbladder Practiced During Open Surgery for Complicated Postbulbar Ulcer; Case Report and Literature Review

Background and Clinical Significance: Typically, late complications of temporary or left-in-situ cholecystostomy in patients with acute calculous cholecystitis are related to retained calculi, which are ultimately resolved by cholecystectomy. Neoformation of gallstones secondary to temporary cholecystostomy in an acalculous (disease-free) gallbladder may be neglected because of a low index of suspicion, until the occurrence of late complications. Case presentation: A 54-year-old female underwent surgery (open procedure, May 2003) for a complicated postbulbar ulcer (stenosis with gastric outlet obstruction; penetration into the common bile duct): troncular vagotomy, distal hemigastrectomy, Roux-en-Y gastrojejunostomy. Temporary cholecystostomy (in an acalculous gallbladder) was added as a supplementary precaution to prevent duodenal stump leakage. Despite medical advice, she never presented for control and was lost for follow-up. The patient (now aged 75) was urgently admitted 21 years later (September 2024) with acute pain in the right upper abdominal quadrant and fever. She was unable to provide medical documentation and had a poor recall of surgical history; we were able to retrieve the operative report because the patient had been operated in our clinic. Physical examination was suggestive of an abscess, overlying cellulitis centered on spontaneous purulent discharge (presumed through the pre-existing drainage tract of the previous cholecystostomy). Abdominal CT demonstrated: emphysematous calculous cholecystitis, an abdominal abscess, and cholecystocutaneous fistula. A transverse incision, centered on the cutaneous fistulous orifice, was followed by discharge of pus and calculi, parietal debridement, and extraction of a fragment of gangrenous gallbladder tissue. Magnetic resonance cholangiopancreatography (MRCP) on day 17 demonstrated a remnant gallbladder containing multiple calculi; the patient was advised to undergo complete cholecystectomy, but once again, neglected medical advice and was lost for follow-up. Conclusions and Further Directions: Temporary cholecystostomy in a disease-free (acalculous) gallbladder, associated with gastric surgery, leads to gallbladder dysmotility and neoformation of gallstones. The first clinical manifestation of silent, undetected neo-formatted calculi may consist of late, potentially lethal, biliary complications. Patients must be subjected to follow-up because the incidence of neo-formed calculi is higher than expected, compared with common gallstones. Prophylactic cholecystectomy for asymptomatic neo-formatted gallstones is a reasonable choice.