[Gallstone ileus--a diagnostic and indications problem--report on 35 patients]

Cholecystolithotomy, a new approach to reduce recurrent gallstone ileus

The incidence of gallstone ileus (GSI) is increasing. Current treatment options include enterolithotomy with or without cholecystectomy and repair of the biliodigestive fistula. Although most surgeons defer the management of the biliodigestive fistula to avoid the associated morbidity and mortality, this can lead to increased rate of recurrence of GSI by the remaining gallstones. More than 130 cases of recurrent GSI were reported in published works, and the incidence of recurrent GSI is reported to be between 5% and 20%. Some cases of second recurrent attacks have also been reported. Most cases were reported in elderly women with faceted stones during the first 2 months from the first episode of GSI. This article reviews the current treatment options for more than 4,300 reported cases of GSI. A treatment algorithm is recommended based on the severity of the inflammation around the gallbladder, including cholecystolithotomy as a third treatment approach that aims to reduce the risk of recurrent GSI.

Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment

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In this study, 1.9% patients were diagnosed with gallstone ileus among those admitted for small bowel obstruction.

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85% of them underwent a conservative surgical approach mainly consisting in the enterolithotomy.

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Only one complication exceeded grade II in each group and no deaths were reported.

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Mean follow-up was 50 months and only one patient without fistula treatment had recurrent disease; no gallbladder cancer were identified.

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Enterolithotomy without fistula closure proved to be safe and effective for the management of gallstone ileus both on a short and long-term basis.

Background

The treatment of gallstone ileus (GI) consists of surgical removal of the impacted bilestone with or without cholecystectomy and repair of the biliodigestive fistula. The objective of this study was to assess whether sparing patients a definitive biliary procedure adversely influenced the outcome.

Materials and methods

Patients with a diagnosis of GI were reviewed. Two groups were identified: patients who underwent a definitive biliary procedure with relieving the intestinal obstruction (group 1/G1) and those who did not have a definitive biliary procedure (group 2/G2). In G2, patients were evaluated on long-term follow-up for the risk of recurrent GI disease, cholecystitis, cholangitis and gallbladder cancer.

Results

Among 1075 patients admitted for small bowel obstruction, 20 (1.9%) were diagnosed with gallstone ileus. 3 (15%) of these belong to G1, 17 (85%) to G2. The overall postoperative morbidity rate was 35% (7/20) with one complication exceeding grade II in each group. No deaths were reported. Mean follow-up was 50 months. During follow-up, one of G2 patients had recurrent disease. No biliary tract infections or gallbladder cancer were identified.

Conclusion

Enterolithotomy without fistula closure is confirmed to be safe and effective for the management of gallstone ileus both on a short- and long-term basis.

Gallstone ileus: rare and still controversial

BACKGROUND

Gallstone ileus is a rare disease and accounts for about 1-3% of mechanic ileus of the small bowel, but for 25% of all small bowel obstructions in patients older than 65 years. Concomitant cardiorespiratory diseases or diabetes are frequent in older patients and responsible for the high mortality rate. The aim of the present study was to evaluate and discuss different surgical approaches and to analyze the clinical outcome.

METHODS

Four patients with a mean age of 72 years were treated for gallstone ileus at our hospital in the last 10 years. Patients history, operative strategy and their outcome is elucidated and a review of the recent literature is given.

RESULTS

In all patients the operative strategy was a one-stage procedure including enterolithotomy, cholecystectomy and closure of the fistula. The 30-day mortality rate was 25%.

CONCLUSION

One-stage procedure prevents from cholangitis, cholecystitis and recurrent ileus caused by further gallstones but bears the risk of enteric or biliary leakage after fistula closure. It should therefore be reserved for patients presenting in good general condition with a low degree of cholecystitis.