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.     

胆石性肠梗阻的诊断与治疗

胆石性肠梗阻是一种较为少见的机械性肠梗阻,多因胆囊巨大结石通过胆肠内瘘排入肠道引起阻塞性肠梗阻.治疗的关键是梗阻原因的诊断,治疗方法主要为手术治疗.2013年4月苏州大学附属第二医院收治了1例老年胆石性肠梗阻患者.术前经X线片和CT检查胆囊壁增厚与十二指肠粘连窦道形成,左髂区机械性肠梗阻（胆源性结石直径约4 cm）,内科治疗3d后行急诊剖腹探查＋取石术治疗肠梗阻,术中见胆囊无结石,与家属沟通后未切除胆囊,术后随访观察.随访至2013年12月患者恢复较好,复查B超胆囊肠道内瘘口未显示,胆囊炎症消退.     

The operative management of gallstone ileus

INTRODUCTION

Gallstone ileus is an uncommon entity, which accounts for 1–4% of all presentations to hospital with small bowel obstruction and for up to 25% of all cases in patients over 65 years of age. Despite medical advances over the last 350 years, gallstone ileus is still associated with high rates of morbidity and mortality. The management of gallstone ileus remains controversial. Whilst open surgery has been the mainstay of treatment, more recently other approaches have been employed, including laparoscopic surgery and lithotripsy. However, controversy persists primarily in relation to the extent of surgery performed.

MATERIALS AND METHODS

A literature review was performed in an attempt to discover the optimal surgical treatment of gallstone ileus, particularly the timing of biliary surgery. Published articles were identified from the medical literature by electronic searches of Pubmed and Ovid Medline databases, using the search terms ‘gallstone ileus’, ‘gallstone/intestinal obstruction’ and ‘gallstone/bowel obstruction’. The related articles function of the search engines was also used to maximise the number of articles identified. Relevant articles were retrieved and additional articles were identified from the references cited in these articles.

RESULTS AND CONCLUSIONS

The literature on gallstone ileus is composed entirely of retrospective analysis of small numbers of patients accumulated over many years. The question as to whether one stage or interval biliary surgery should be performed remains unanswered and it is unlikely that further case series will help decision making in the management of gallstone ileus. Whilst many authors conclude that enterolithotomy alone is the best option in most patients, a one-stage procedure should be considered for low-risk patients.     

Laparoscopic management of gallstone ileus.

Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in perioperative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed. We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively. Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.     

Laparoscopically assisted enterolithotomy for a gallstone ileus in an atypical location

Mechanical intestinal obstructions caused by gallstones occur in approximately 1% to 2% of cases. In most of the patients, the obstruction occurs at the ileocecal valve. However, gallstones may cause obstruction anywhere along the gastrointestinal tract from the stomach to the sigmoid colon. Laparoscopically assisted enterolithotomy can be used as a treatment method. This report describes a case in which a gallstone blockage caused a mechanical obstruction in an atypical location, which was successfully treated with a laparoscopically assisted approach. No grants were used in support of this project.     

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.     

A single centre case series of gallstone sigmoid ileus management

Aims/IntroductionGallstone sigmoid ileus is a rare condition that presents with symptoms of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon. This arises because of three primary factors: cholelithiasis causing a cholecystoenteric fistula; a gallstone large enough to obstruct the bowel lumen; and narrowing of the bowel.We describe 3 patients treated in a district general hospital over a 3-year period, and discuss their management.MethodsCases were retrospectively analysed from a single center between 2015 and 2017 in line with the SCARE guidelines.Results3 patients – 2 female, 1 male. Age: 89, 68, 69 years. 2 cholecystocolonic fistulae, 1 cholecystoenteric (small bowel) fistula.Patient 1: Unsuccessful endoscopic attempts to retrieve the (5 × 5 cm) gallstone resulted in surgery. Retrograde milking of the stone to caecum enabled removal via modified appendicectomy.Patient 2: Endoscopy and lithotripsy failed to fragment stone. Prior to laparotomy the stone was palpated in the proximal rectum enabling manual extraction.Patient 3: Laparotomy for gallstone ileus failed to identify a stone within the small bowel. Gallstone sigmoid ileus then developed. Conservative measures successfully decompressed the large bowel 6 days post-operation.ConclusionsThis is the first case series highlighting the differing strategies and challenges faced by clinicians managing gallstone sigmoid ileus. Conservative measures (including manual evacuation), endoscopy, lithotripsy and surgery all play important roles in relieving large bowel obstruction. It is essential to tailor care to individual patients’ needs given the complexities of this potentially life threatening condition.     

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目的 提高对胆石性肠梗阻的认识，及时明确诊断和手术治疗。方法 回顾性分析１３例胆石性肠梗阻的临床及影像学资料。结果 １３例均经手术治愈，仅３例术前确诊为胆石性肠梗阻。结论 滚动性梗阻是胆石性肠梗阻的特征，及时的Ｂ超和Ｘ线检查有助于早期明确诊断，手术解除结石梗阻是唯一的治疗手段。     

Single-incision laparoscopic surgery for gallstone ileus: An alternative surgical procedure

INTRODUCTION

Gallstone ileus (GI) results from the passage of a stone through a cholecystoenteric fistula, subsequently causing a bowel obstruction. The ideal treatment procedure for GI remains controversial.

PRESENTATION OF CASE

A 63-year-old female was admitted to our hospital following persistent nausea and vomiting for 7 days. Computed tomography revealed a partially calcified 4-cm circular object in the jejunum, and the proximal intestine was dilated, with concomitant pneumobilia. Based on the preoperative diagnosis of GI, enterotomy with stone extraction by single-incision laparoscopic surgery (SILS) was performed. The patient''s postoperative course was uneventful, and the cholecystoduodenal fistula closed spontaneously 4 months after the surgery.

DISCUSSION

Recent studies have reported that enterotomy with stone extraction alone is associated with better outcomes than with more invasive techniques. This case also suggests that enterotomy with stone extraction alone and careful postoperative follow-up is feasible for the management of GI. Although the use of laparoscopy in the management of GI has been described previously, laparoscopic surgery has not been widely performed, and SILS is not generally performed. When only this less demanding procedure is required, laparoscopic surgery, including SILS, can be a viable option.

CONCLUSION

SILS can be an alternative surgical procedure for the management of GI.     

Recurrent small bowel obstruction after laparoscopic surgery for gallstone ileus

Gallstone ileus is an uncommon cause of small bowel obstruction. A patient presenting with gallstone ileus was managed in our department by laparoscopic enterolithotomy. Postoperatively, the patient developed recurrent small bowel obstruction due to the presence of a second gallstone. It is therefore important to exclude the possibility of multiple gallstones at the initial operation.     

胆石性肠梗阻的影像学诊断

胆石性肠梗阻是一种罕见且具有潜在危险性的胆石症并发症,临床表现不典型,术前诊断困难。2005年3月至2012年9月上海市浦东新区人民医院收治了19例经手术或内镜检查证实的胆石性肠梗阻患者。患者术前X线片、超声、CT、MRI检查诊断准确率分别为0／10、0／5、19／19、9／9。CT检查可作为胆石性肠梗阻的首选检查方法。典型的CT表现为Rigler三联征：肠腔异位结石、机械性肠梗阻及胆道积气。MRI检查对瘘口的显示优于CT检查,可提供更为丰富全面的影像学信息,对手术方案的制订及预后的判断有重要参考价值;X线片及超声检查仅作为筛查手段。     

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.     

“Bouveret's syndrome” presenting with acute pancreatitis a very rare and challenging variant of gallstone ileus

INTRODUCTIONBouveret's syndrome is a rare variant of gallstone ileus and describes gastric outlet obstruction secondary to an impacted stone in the duodenum. Its presentation is vague and clinical diagnosis is often difficult resulting in a delay in diagnosis.PRESENTATION OF CASEWe report a patient who presented initially with non-specific symptoms and subsequently with features in keeping with acute pancreatitis, but eventually was found to have Bouveret's syndrome.DISCUSSIONDifferent treatment strategies are discussed. Although endoscopic treatment combined with many newer modalities like lithotripsy have been tried, surgery remains the definitive management in the vast majority of cases.CONCLUSIONBouveret's syndrome is a rare condition, can also present as pancreatitis and often difficult to diagnose initially, but with appropriate treatment has a good outcome.     

Gallstone ileus,clinical presentation,diagnostic and treatment approach

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract. Less than 1% of cases of intestinal obstruction are derived from this etiology. The symptoms and signs of gallstone ileus are mostly nonspecific. This entity has been observed with a higher frequency among the elderly, the majority of which have concomitant medical illness. Cardiovascular, pulmonary, and metabolic diseases should be considered as they may affect the prognosis. Surgical relief of gastrointestinal obstruction remains the mainstay of operative treatment. The current surgical procedures are:(1) simple enterolithotomy;(2) enterolithotomy, cholecystectomy and fistula closure(one-stage procedure); and(3) enterolithotomy with cholecystectomy performed later(two-stage procedure). Bowel resection is necessary in certain cases after enterolithotomy is performed. Large prospective laparoscopic and endoscopic trials are expected.     

胆石性肠梗阻的诊治进展

胆石性肠梗阻是胆石症的罕见并发症之一,多见于老年患者.该病临床表现缺乏典型性,术前确诊有很大难度,腹部CT平扫是首选的诊断方式.手术治疗是目前最主要的治疗手段,要根据患者的自身情况,选择个体化的手术方式.内镜、腹腔镜等微创取石术是很有前景的治疗手段,随着相关技术的发展将会越来越多的运用于胆石性肠梗阻的治疗.     

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

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

Recurrent gallstone ileus

We present the case of a recurrent gallstone ileus in a 76-year old female patient, which presented at our emergency department on January 15th 2015. In both episodes (January 16th and February 1st, 2015), only a simple enterotomy with stone extraction was performed. One year later, she is fully recovered and in good health. Recurrent gallstone ileus most often occurs in elderly patients with multiple co-morbidities. In our aging population, its prevalence is expected to increase. Because of the vague, intermittent symptoms, diagnosis of gallstone ileus is often delayed, contributing to its high mortality rate. CT-scan has become the preferred diagnostic imaging modality. Treatment should be individualized, with stone removal by enterotomy alone being the most commonly used strategy. For symptomatic patients, a two-stage procedure with urgent enterotomy followed by a delayed cholecystectomy can be considered. The one-stage procedure, in which enterotomy is combined with cholecystectomy and fistula closure, should be reserved for those few patients with minimal cholecystitis and in good overall condition.     

胆石性肠梗阻的诊断和治疗

目的 本文旨在提高对胆石性肠梗阻的认识，及时明确诊断和手术治疗。方法 回顾性分析15例胆石性肠梗阻的临床及影像学资料。结果 15例均经手术治愈，5例术前确诊为胆石性肠梗阻，但入院前确诊仅1例。结论 提高胆石性肠梗阻发生的警惕性，早期诊断和早期手术，取得最佳治疗效果是可能的。     

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.