Gallbladder necrosis after gastrectomy is very rare, and intractable hiccups caused by gallbladder necrosis is even more rare. Its clinical presentations and management strategies have not been described in available literature. This report firstly describes the clinical presentations, cause, management strategies, and treatment outcome of intractable hiccups immediately after gastrectomy. When intractable hiccups occurs after gastrectomy and abdominal computed tomography (CT) indicates gallbladder enlargement, gallbladder necrosis should be considered. After cholecystectomy or ultrasound-guided percutaneous gallbladder drainage, the patients were successfully treated.
gallbladder necrosisgastrectomygastric cancerintractable hiccupspostoperative complicationThe author(s) declared that financial support was received for this work and/or its publication. This study was supported by the National Natural Science Foundation of China (grant number: 82060561), the Natural Science Foundation of Guangxi Province (grant number: 2018GXNSFBA050047), Innovation Project of Guangxi Graduate Education (grant number: YCSW2022379).section-at-acceptanceVisceral SurgeryIntroduction
Gastric cancer (GC) is one of the most common cancer and the fifth leading cause of cancer-related mortality worldwide (1). Surgery remains the mainstay of treatment for locally advanced gastric cancer. Despite the developments in gastric cancer surgery aimed at improving outcomes, the radical gastrectomy is still a high-risk procedure (2–5). Studies report that the incidence of postoperative complications after D2 gastrectomy ranges from 12.8% to 14% (6–8). Major complications include hemorrhage, anastomotic leakage, lymphatic leak, pancreatic fistula, ileus and cholecystitis. Reports of hiccups after gastrectomy are very rare, particularly in intractable hiccups. Here, we first report two cases of intractable hiccups induced by gallbladder necrosis after laparoscopic distal D2 gastrectomy.
Case presentationCase 1
A 77-year-old man with gastric antral adenocarcinoma underwent laparoscopic-assisted radical distal gastrectomy with D2 lymphadenectomy (Billroth II) in our department in May 2017. The patient had no preoperative history of gallstones and cholecystitis. On postoperative day 5, the patient developed intractable hiccups following eating semiliquid diet, which persisted despite conservative management including Valsalva maneuver, carotid sinus massage, and digital ocular pressure. Moreover, the patient was treated with different drugs, including metoclopramide, chlorpromazine, and herbal medicine, the symptoms also could not be relieved. Physical examination revealed right upper quadrant abdominal tenderness and muscle tension, but without rebound tenderness and Murphy's sign. Laboratory findings showed progressively elevated white blood cell count, but the bilirubin level was normally. Abdominal drainage exhibited normal ascites without early anastomotic leakage. In addition, upper gastrointestinal angiography showed no evidence of anastomotic leakage (Figure 1). Abdominal CT scan demonstrated enlarged gallbladder on day 7 after operation (Figure 2). Ten days after operation, the patient developed acute diffuse peritonitis and underwent laparotomy. Intraoperative findings revealed gallbladder necrosis and cholecystectomy was performed. The postoperative pathological results also confirmed gallbladder necrosis (Figure 3). The patient recovered well after operation and was discharged without complications.
Upper gastrointestinal angiography showed no signs of anastomotic leakage.
X-ray image showing a section of the human gastrointestinal tract with visible contrast material outlining the stomach and intestines, highlighting the internal structures and folds.
Computed tomography (CT) scan showing normal gallbladder before operation (A), enlarged gallbladder on day 7 after operation (B).
Two CT scan images labeled A and B show cross-sectional views of the abdomen. Both images display the spine, organs, and varying densities of tissues. Structural details and calibration markings are visible around each scan. Image A on the left differs slightly in detail and positioning from Image B on the right.
HE staining showed gallbladder necrosis.
Microscopic view of a tissue sample stained for examination. Dense clusters of small, darkly stained cells are dispersed throughout a pink-stained background with scattered larger red cells.Case 2
A 58 year-old-man with gastric antral adenocarcinoma underwent laparoscopic-assisted distal D2 gastrectomy (Billroth II) in our department in October 2023. The patient had no history of gallstones and cholecystitis. On postoperative day 4, the patient developed intractable hiccups that failed to respond to pharmacologic interventions, including metoclopramide, chlorpromazine and traditional Chinese medicine. Physical examination revealed no signs of peritonitis, and abdominal drainage tubes showed normal ascites without early anastomotic leakage. Laboratory findings demonstrated leukocytosis (WBC up to 19 × 10⁹/L) and progressive hyperbilirubinemia (total bilirubin peaked at 99 μmol/L). Abdominal CT demonstrated only gallbladder edema without subdiaphragmatic abscess or effusion (Figure 4). In view of the experience of the previous case, consultation with hepatobiliary surgeons suggested gallbladder necrosis. On postoperative day 8, ultrasound-guided percutaneous gallbladder drainage was performed. The gallbladder puncture drained purulent turbid bile. After drainage, the patient's hiccup symptoms disappeared, white blood cells and bilirubin gradually returned to normal, and was discharged without complications.
Computed tomography (CT) scan showing normal gallbladder before operation (A), enlarged gallbladder on day 8 after operation (B).
CT scan images labeled A and B display cross-sectional views of the abdomen. Both images show abdominal organs with varying densities. Scale markers and technical details like kilovoltage, milliamps, field of view, and slice thickness are included on each image. Image A appears slightly different in detail compared to Image B, possibly due to different scanning settings or patient positioning.Discussion
At present, radical gastrectomy remains the cornerstone of gastric cancer management (9–11). We have reported for the first time two cases of refractory hiccup caused by gallbladder necrosis after laparoscopic distal D2 radical gastrectomy, which provides a treatment method for other doctors encountering similar cases. In traditional beliefs, postoperative hiccups are often attributed to diaphragmatic stimulation, gastric dilation, or central nervous system factors. But the intractable hiccups caused by gallbladder necrosis provides a new perspective for general surgeons.
In these two cases of gallbladder necrosis, the first case of intractable hiccups was managed conservatively, but it showed no improvement. Laparotomy was delayed until the patient developed acute generalized peritonitis, with intraoperative identification of gallbladder necrosis. After cholecystectomy, the patient recovered well and was discharged without complications. The second patient had intractable hiccups accompanied by progressive increase in bilirubin. Abdominal CT showed gallbladder enlargement and edema. Drawing on insights from the prior case, we suspected gallbladder necrosis. After ultrasound-guided gallbladder puncture and drainage, the patient's intractable hiccups gradually resolved, bilirubin levels returned to normal, and he was discharged without complications.
It is well known that laparoscopic D2 gastrectomy necessitates the dissection of No. 8 and No. 12 lymph nodes, which may damage the cystic artery. Moreover, the anatomical variation rate of the cystic artery ranges from 10% to 35% (12). These may contribute to postoperative gallbladder necrosis. According to the literature, the incidence of cholecystitis following D2 gastrectomy ranges from 15% to 25%, even when the cystic artery is preserved intraoperatively (13, 14). This phenomenon may result from intraoperative injury to the vagus nerve during the dissection of No. 8 and No. 12 lymph nodes.
Therefore, the possible causes of intractable hiccups secondary to gallbladder necrosis are as follows: firstly, inflammation and edema of the gallbladder can stimulate the nerve endings within the gallbladder wall. These neural signals are either transmitted to the central nervous system or directly spread to the adjacent phrenic nerve branches, resulting in involuntary paroxysmal spasms of the diaphragm and subsequent onset of hiccups. Secondly, gallbladder enlargement and edema of the surrounding tissues can exert upward compression on the diaphragm, altering its normal anatomical position and tension, which in turn induces hiccups.
To prevent postoperative gallbladder necrosis, the surgeon should perform a preoperative review of abdominal CT to identify the origin of the right gastric artery. Careful intraoperative dissection is essential to avoid cystic artery injury. Postoperative gallbladder necrosis following gastric cancer surgery often presents with a delayed onset, making it difficult for surgeons to detect intraoperatively. Therefore, if the patient develops intractable hiccups, progressive elevation of bilirubin, or gallbladder edema postoperative, the possibility of gallbladder necrosis should be considered. Based on our clinical experience, ultrasound-guided gallbladder puncture and drainage is an efficient and safe treatment option, which can avoid secondary operation and is more readily to accept by the patient.
Conclusion
Gallbladder necrosis after laparoscopic radical gastrectomy is a rare but life-threatening complication. Therefore, if a patient develops intractable hiccups postoperatively, accompanied by progressive bilirubin elevation and gallbladder edema, the possibility of gallbladder necrosis should be considered. Ultrasound-guided gallbladder puncture and drainage is an efficient and safe treatment option. To prevent such complications, carefully preoperative abdominal CT review and intraoperative dissection are essential.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies involving humans were approved by The study protocol was approved by the Ethics and Scientific Committee of the Guilin people's hospital (GPH202100321) and conforms to the Declaration of Helsinki. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
ZZ: Writing – original draft, Writing – review & editing. JL: Writing – original draft, Writing – review & editing.
Acknowledgments
We thank the reviewers and editors for their work.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was not used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
ReferencesSundarRNakayamaIMarkarSRShitaraKvan LaarhovenHWMJanjigianYYGastric cancer. Lancet. (2025) 405(10494):2087–102. 10.1016/S0140-6736(25)00052-240319897HuYHuangCSunYSuXCaoHHuJMorbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer: a randomized controlled trial. J Clin Oncol. (2016) 34(12):1350–7. 10.1200/JCO.2015.63.721526903580van der VeenABrenkmanHJFSeesingMFJHaverkampLLuyerMDPNieuwenhuijzenGAPLaparoscopic versus open gastrectomy for gastric cancer (LOGICA): a multicenter randomized clinical trial. J Clin Oncol. (2021) 39(9):978–89. 10.1200/JCO.20.0154034581617LouSYinXWangYZhangYXueY. Laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis of randomized controlled trials. Int J Surg. (2022) 102:106678. 10.1016/j.ijsu.2022.10667835589049BoTZhihongPPeiwuYFengQZiqiangWYanSGeneral complications following laparoscopic-assisted gastrectomy and analysis of techniques to manage them. Surg Endosc. (2009) 23(8):1860–5. 10.1007/s00464-008-0312-319184208WangSXuLWangQLiJBaiBLiZPostoperative complications and prognosis after radical gastrectomy for gastric cancer: a systematic review and meta-analysis of observational studies. World J Surg Oncol. (2019) 17(1):52. 10.1186/s12957-019-1593-930885211KimHHHanSUKimMCHyungWJKimWLeeHJLong-term results of laparoscopic gastrectomy for gastric cancer: a large-scale case-control and case-matched Korean multicenter study. J Clin Oncol. (2014) 32(7):627–33. 10.1200/JCO.2013.48.855124470012YuJHuJHuangCYingMPengXWeiHThe impact of age and comorbidity on postoperative complications in patients with advanced gastric cancer after laparoscopic D2 gastrectomy: results from the Chinese laparoscropic gastrointestinal surgery study (CLASS) group. Eur J Surg Oncol. (2013) 39(10):1144–9. 10.1016/j.ejso.2013.06.02123850088LiGZDohertyGMWangJ. Surgical management of gastric cancer: a review. JAMA Surg. (2022) 157(5):446–54. 10.1001/jamasurg.2022.018235319717WangYZhangLYangYLuSChenH. Progress of gastric cancer surgery in the era of precision medicine. Int J Biol Sci. (2021) 17(4):1041–9. 10.7150/ijbs.5673533867827UshimaruYOmoriTYamamotoKYanagimotoYMasuikeYMatsuuraNRobotic and laparoscopic gastrectomy for gastric cancer: comparative insights into perioperative performance and three-year survival outcomes. Gastric Cancer. (2025) 28(3):514–26. 10.1007/s10120-025-01601-140009253TriantafyllouGBelimezakisNLyrosOTsakotosGBotisGPiagkouM. Surgical anatomy of the cystic artery: a systematic review with meta-analysis. Ann Anat. (2025) 257:152343. 10.1016/j.aanat.2024.15234339369802KimuraJKunisakiCTakagawaRMakinoHUedaMOtaMIs routine prophylactic cholecystectomy necessary during gastrectomy for gastric cancer?World J Surg. (2017) 41(4):1047–53. 10.1007/s00268-016-3831-427896408ChoiYSChaBKimSHYiJWKimKDChoiMSClinical characteristics of symptomatic cholecystitis in post-gastrectomy patients: 11 years of experience in a single center. Medicina (Kaunas). (2022) 58(10):1451. 10.3390/medicina5810145136295611
Edited by: Gabriel Sandblom, Karolinska Institutet (KI), Sweden
Reviewed by: Liang Wang, Affiliated Hospital of Qinghai University, China
Tomasz Muszyński, Jagiellonian University Medical College, Poland
Jair Diaz Martinez, Hospital Centenario de la Revolucion Mexicana, Mexico