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.     

胆囊十二指肠瘘伴胆石性肠梗阻1例分析并文献复习

目的:探讨胆囊十二指肠瘘合并胆石性肠梗阻的术前评估、诊断和手术方式。方法:回顾性分析1例胆囊十二指肠瘘合并胆石性肠梗阻术前及术中的临床资料,并复习相关文献。结果:患者术前CT检查考虑胆囊结石与胆石性肠梗阻。术中探查见回盲部40cm处结石嵌顿,随后成功行肠切开取石、十二指肠瘘口修补、胆囊切除。术后痊愈出院,随访至目前未见相关并发症。结论:胆囊十二指肠瘘合并胆石性肠梗阻临床罕见,早期的明确诊断及精确的评估是关键,应根据患者具体情况选择合适的手术方式。     

胆石性肠梗阻五例报告并文献复习

目的 探讨胆石性肠梗阻的临床特点及诊治方法.方法 回顾性分析5例胆石性肠梗阻患者的临床资料,并复习2000-2009年国内相关文献,对胆石性肠梗阻的发病情况、临床表现、影像学检查、诊断及治疗情况进行总结.结果 本组5例患者中4例为60岁以上女性,其中3例有胆石病史,胆石经胆囊十二指肠瘘排入肠道 另2例有胆肠内引流术史,胆石经内引流口排入肠道.4例行肠切开取石并肠道胆道彻底手术,另1例行单纯肠切开取石 5例患者均手术治愈,术后无复发病例.国内文献复习共获取胆石性肠梗阻有效病例441例,占所有肠梗阻的1.15%,其中女性患者占67.12%,老年患者占73.56%.87.92%的胆石是经胆肠内瘘口排入肠道 64.17%的梗阻位于回肠.术前有71.89%的患者误诊为其他类型肠梗阻.225例行肠切开取石并肠道胆道彻底性手术,其术后复发率及胆囊癌变率低于216例行单纯肠切开取石患者（均P＜0.05） 而术后胆肠瘘、切口感染、肺部感染、治愈率及死亡率两种术式间差异则无统计学意义（均P＞0.05）.结论 胆石性肠梗阻发病率低,以老年女性多见 胆石多经胆肠内瘘口进入肠道,梗阻部位以回肠多见.单纯肠切开取石术后有一定的复发及胆囊癌变风险,故若患者全身情况允许,应首选肠切开取石并胆道肠道彻底性手术.     

Laparoscopic Enterolithotomy Is a Valid Option to Treat Gallstone Ileus

Gallstone ileus is a well-recognized clinical entity. It usually affects elderly female patients, and very often diagnosis can be delayed resulting in high morbidity and mortality. An abdominal x-ray and computed tomographic (CT) scan of the abdomen may show classical radiological features of small bowel obstruction, pneumobilia, and an ectopic gallstone. Laparotomy and enterlithotomy with or without definite biliary surgery is an established treatment. Since 1992, many cases of laparoscopic-assisted enterolithotomy have been reported. Only a few cases of a totally laparoscopic approach have been documented. We present the case of a 75-year-old lady who presented with features of intestinal obstruction. A plain x-ray of the abdomen and a CT scan confirmed the classical features of gallstone ileus. A totally laparoscopic enterolithotomy was performed using 6 ports. A 6-cm gallstone was retrieved through a longitudinal enterotomy. The transverse closure of the enterotomy was performed with intracorporeal suturing, resulting in an uneventful postoperative recovery. We suggest that a CT scan helps in the early diagnosis of the cause of intestinal obstruction, and totally laparoscopic enterolithomy with intracorporeal enterotomy repair is a valid, safe option.     

Bouveret's Syndrome Complicated by Classic Gallstone Ileus: Progression of Disease or Iatrogenic?

Case Presentation

Bouveret's syndrome is a rare variant of gallstone ileus resulting in gastroduodenal obstruction from an impacted gallstone. We report two cases of Bouveret's syndrome that were complicated by classic (distal) gallstone ileus, which has previously been reported only twice. The first patient presented with vomiting, epigastric pain, and what was initially believed to be a duodenal diverticulum on computed tomography scan and endoscopy. He initially improved, but later developed symptoms of a small bowel obstruction. Repeat imaging revealed a classic distal gallstone ileus. The second patient presented with nausea, abdominal pain, and imaging consistent with Bouveret's syndrome. Multiple non-operative endoscopic techniques and extracorporeal shock wave lithotripsy were employed to fragment and retrieve the obstructing stone, and she subsequently developed a distal gallstone ileus from a stone fragment. Both patients were managed operatively with enterotomy and stone removal.

Discussion

These cases highlight a rare complication of Bouveret's syndrome, classic (distal) gallstone ileus, and juxtapose the natural history of a stone passing versus an iatrogenic etiology. We review the presentation and management of Bouveret's syndrome though no clear consensus exists as to the optimal treatment of these patients. We recommend that therapy should be decided on a case-by-case basis.     

Comparison of Surgical Treatments of Gallstone Ileus: Preliminary Report

Abstract Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for only 1% to 4% of all intestinal obstructions. In the group of patients over 65 years of age, gallstones cause about 25% of all non-strangulated obstructions of the small bowel. Gallstone ileus is burdened with high mortality rate, ranging from 12% to 18%, and most patients are of advanced age, with many other concomitant diseases that may increase the operative risk. The purpose of this study was to compare the two investigated surgical procedures: treatment of intestinal obstruction alone or combined with urgent cholecystectomy and fistula repair. Analysis of 30 patients undergoing operation for gallstone ileus at the Clinical Hospital “Sestre milosrdnice” between 1985 and 2001 is presented. Patients were treated either for ileus alone (group 1, 11 patients) or as one-stage procedure with urgent fistula closure (group 2, 19 patients). Operating time was significantly longer for the one-stage procedure. Complications occurred in 3 of 11 patients (27.3%) from group 1 and in 11 of 18 patients (61.1%) from group 2 (one tailed, p = 0.043). One patient in group 1 died and two patients in group 2 died. Urgent fistula repair was significantly associated with the occurrence of complications (odds ratio [OR] 12.1, 95% confidence internal [95% CI] 1.2–121.5). Simple enterotomy should be the procedure of choice for patients with gallstone ileus. The one-stage procedure including urgent fistula repair should be reserved only for highly selected patients with absolute indications.     

Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature

Ten patients with gallstone ileus were studied to evaluate diagnostic and therapeutic procedures. The preoperative diagnosis was correct in four patients. All patients underwent laparotomy. In five patients, stones were removed by enterotomy and in three patients the obstruction was relieved by manual propulsion of the stones. One-stage small-bowel resection, cholecystectomy, and biliary enteric fistula repair were performed in two patients. Four patients had uneventful recovery. One episode of recurrent gallstone ileus was encountered. Three patients died of septic complications. It is concluded from the study and from a review of the literature that treatment should be aimed at relieving the obstruction, without performing additional surgical procedures, such as cholecystectomy and fistula repair. Secondary biliary surgery is to be performed only in patients with recurrent biliary disease.     

Gallstone ileus in cholecystoduodenal fistula]

Operations were performed on 15 patients with obturation gallstone ileus, 8 of them had a cholecystoduodenal fistula and the authors analysed their case records. It is most difficult to establish the diagnosis of the subacute form of the disease which is caused by slow movement of the stone in the intestine, which conceals the clinical picture and leads to delay of operation. The operation of choice is resection of the small intestine together with the stone or enterotomy with obligatory evacuation of contents from the proximal parts of the intestine. The mortality in the group of patients operated on later than on day 4 after the onset of the disease is very high and, according to our data, it is 100%. An obligatory condition of the operation is evacuation of the contents from the intestine in order to reduce intoxication and prevent endotoxic shock.     

胆石性肠梗阻的诊治(附11例临床分析)

目的探讨胆石性肠梗阻的临床特点和治疗方法. 方法我院1985年～2000年共收治胆石性肠梗阻11例,术前仅3例确诊.均经手术治疗,其中10例行肠管切开取石,1例因肠坏死切除坏死肠段.失访2例,余9例患者一期术后6～9月行胆囊切除和(或)内瘘修补术. 结果Ⅰ期手术后并发呼吸道感染2例,切口感染1例,随访结果显示Ⅱ期手术后9例患者均获治愈. 结论胆石性肠梗阻术前确诊率低,但及时的B超及X线检查有助于其早期诊断,分期手术治疗胆石性肠梗阻效果显著.     

Gallstone ileus as a complication of acute cholecystitis. Laparoscopic diagnosis and treatment

Gallstone ileus accounts for 1-4% of all cases of intestinal obstruction, with its incidence rising with age of patients. There is often a long delay between onset of symptoms (usually abdominal pain, vomiting, and bowel distension) and proper treatment, with a simple enterolithotomy as the one of choice. We report a case of an atypical gallstone ileus presented as a complication of acute cholecystitis, treated with a laparoscopic guided enterolithotomy. A 67-year-old woman on the 5th p.o. day after a laparoscopic procedure for an empyematous cholecystitis (no sign of fistula or duodenal perforation and a "negative" intraoperative cholangiography) presented continuous vomiting as the only symptoms of a subileus (radiographic diagnostic images negative for intestinal obstruction or intraluminal gallstone or duodenal fistula). A laparoscopic diagnostic approach revealed a gallstone in the distal jejunum. Through a 5 cm midline incision the intestine, including the gallstone, was brought out extracorporally and the stone was removed by a simple enterolithotomy. The postoperative course was uneventful and the patient had no complaint at a 1-year follow-up. We consider the laparoscopic approach, in patients with "abdominal emergencies," feasible and safe in experienced hands. It provides diagnostic accuracy as well as therapeutic capabilities, as in the case of gallstone ileus we have reported.     

Gallstone Ileus in a Patient with Crohn’s Disease: a Case Report

Gallstone ileus is a rare complication of cholelithiasis. Only 0,3–0,5% of all patients with gallstones will eventually suffer from this condition. It is well known that there is an increased prevalence of gallstones among patients with Crohn’s disease, but gallstone ileus remains even in these patients an unfrequent condition. Because of the rarity of this disease and its presentation as an intestinal (sub)obstruction, mostly without biliary symptoms, diagnosis and surgical treatment are often delayed. We report the case of a 75-year-old woman with a long history of Crohn’s disease presenting with intermittent symptoms of intestinal obstruction since several weeks. Symptoms were thought to be due to recurrence of Crohn’s disease, but the patient did not respond to steroid therapy. Resection of the diseased ileocolic segment was performed and a large impacted stone was detected proximal of the stenotic segment. With this case report we want to emphasize how easily diagnosis of gallstone ileus can be missed, especially in Crohn’s patients and we would like to discuss the different treatment options.     

A forgotten cause of intestinal obstruction in a 96-year-old female

Aim-Background

Gallstone ileus is a mechanical bowel obstruction caused by a biliary calculus originating from a bilioenteric fistula. It is a rare surgical disease and occurs in the elderly with female propensity.

Case presentation

We report the case of a 96-year-old female patient, 6 gravida, 6 para who was admitted to our clinic for abdominal pain, vomiting, constipation and flatulence. The patient underwent an exploratory laparoscopy with a midline incision. Intraoperatively, a gallstone measuring 5x3x2.6 cm was found in the ileum 80 cm from the ileocaecal valve. The stone was extracted by means of a longitudinal enterotomy. The postoperative course was uneventful.

Conclusion

Gallstone ileus is an uncommon disease. Exploratory laparotomy with enterolithotomy offers advantages in cases of elderly patients with diagnostic delay. With the advancements of surgical technology (lithotripsy, endoscopy), treatment has taken a step forward, providing reasonable options for gallstone obstruction. The patient’s performance status should be considered (tolerance of major surgical procedure), before proceeding with any of the current operative options.     

Gallstone ileus in the absence of the gallbladder: case report and review of the literature

Although small-bowel obstruction due to gallstone ileus is uncommon, it assumes increasing importance with advancing age. The obstructing gallstone enters the bowel through an internal fistula between gallbladder and duodenum. The authors describe the case of a patient who had undergone cholecystectomy and in whom gallstone ileus occurred secondary to a stone that entered the bowel through a choledochoduodenal fistula. Treatment was traditional with removal of the obstructing stone, but the fistula was left undisturbed. The authors believe that further biliary tract symptoms are unlikely. The patient was well 8 weeks after operation and roentgenograms indicated that the internal biliary fistula was patent.     

Gallstone ileus as a complication of cholecystolithiasis

Biliary fistula and gallston ileus are rarely found. The diagnosis is difficult. Gallstone ileus requires urgent and appropriate surgical therapy. Enterolitotomy remains the gold standard of operative treatment for gallstone ileus, but additional procedures of one-stage cholecystectomy and repair of fistula are necessary. Some researchers advise first to resolve the gallstone ileus and then to perform the elective operation for gallstone disease in more ideal circumstances. Our case had clinical evidence of ileus, which was confirmed by radiological exam. Ultrasonographic examination performed before operation did not confirm the presence of gallbladder; it did not detect a large stone located in the intestine. The patient, a 75-year-old woman, was operated on. During the procedure it was shown that the second part of the duodenum was involved in a scar and displaced to the hepatic hilus. There was no gallbladder; it was probably destroyed by a long-lasting vesicoduodenal fistula. Cholangiography also did not detect the gallbladder. Biliary passage through the common bile duct was sufficient. The hole in the duodenum wall was sutured, and Kehr drain was inserted into the common bile duct. The gallstone was removed by incision of the intestine down to the obstruction. The postoperative period was complicated by a small suppuration of the laparotomy wound. Vesicoduodenal fistula present for a long time can lead to atrophy of the gallbladder. The one-stage procedure seems to be appropriate if biliary fistula and gallstone ileus are found.     

Gallstone ileus in patient with Crohn’s disease

Gallstone ileus is an uncommon form of bowel obstruction, related in the majority of cases to a cholecystoenteric fistula. In patients with Crohn’s disease the stone can obstruct the diseased bowel. We report a case of gallstone ileus in a patient with Crohn’s disease. An explorative laparoscopy and a minimally-invasive laparotomy were achieved to resolve the obstruction. Cholecystectomy and closure of the cholecystoduodenal fistula were not performed. The association of gallstone ileus and Crohn’s disease is very rare; only few cases are reported in the literature. Laparoscopic approach could identify the extension of the disease and the site of impaction, allowing the differential diagnosis in particular in patients with Crohn’s disease. In the cases described, cholecystectomy and the closure of the fistula were not performed considering the absence of any residual stone in the gallbladder and the associated risk of treating the cholecysto-duodenal fistula in an emergency settings.     

Gallstone Ileus: Diagnosis and Management

BACKGROUND: Gallstone ileus is a rare complication of cholelithiasis, mostly in the elderly. It accounts for 1%-4% of mechanical bowel obstruction and is associated with high morbidity and mortality. We present our experience of gallstone ileus and discuss current opinion as reported in the literature. PATIENTS AND METHODS: A retrospective review was performed of medical records of patients in our institution coded for gallstone ileus by the International Classification of Diseases (ICD K-563) coding system between January 1998 and December 2005. RESULTS: There were 22 patients with mean age of 77 (58-92) years and a female to male ratio of 4.5:1. Most patients presented with abdominal pain and vomiting, with a median duration of symptoms of 3 (1-28) days. Preoperative diagnosis was made in 77% from a combination of plain x-ray, ultrasonography, and computed tomography (CT) scans; 86.4% of the patients belonged to ASA class of 3 or 4. Twenty patients underwent enterolithotomy alone, and two had one-stage procedure. The mean size of impacted stones was 3.6 (2.5-4.5) cm, with location in the terminal ileum in 17 and jejunum in 5 patients. There were 5 perioperative deaths and an episode of cholangitis occurring in one patient 18 months after enterolithotomy alone. CONCLUSIONS: Gallstone ileus is a difficult clinical entity to diagnose. Unreserved use of imaging techniques can improve diagnostic accuracy and speed of therapeutic decision making. Management of gallstone ileus must be individualized. The one-stage procedure should be offered only to highly selected patients with good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation.     

GALLSTONE ILEUS: POST CHOLECYSTECTOMY

A case of gallstone ileus occurring 5 months after laparoscopic cholecystectomy is presented. The possible aetiology is discussed and the literature regarding consequences of intraperitoneal stone spillage reviewed.     

Laparoscopic cholecystectomy

Background: The wide acceptance of laparoscopic cholecystectomy (LC) has resulted in increased rates of cholecystectomy. However, the increased rate of LC bears the possibility of concomitantly missing other intra-abdominal pathologic states that exist concurrently with this procedure. The purpose of this report was to evaluate data on LC with regard to missed pathologies of other organs in a clinical prospective follow-up. Methods: The clinical prospective follow-up of 676 patients treated laparoscopically for gallstone disease at our unit since January 1993, was studied. Converted procedures were excluded from the follow-up study. Results: Among 676 patients who underwent LC, 4 patients (0.6%) required readmission for missed pathology of another organ. The diagnostic delay ranged from 2 weeks to 7 months. The readmissions were due to colonic cancer (2 cases), carcinoma of the stomach (1 case), and fibrosis of the mesenterium of small bowel causing ileus (1 case), which are demonstrated in detail. According to retrospective analysis of the symptoms, none of the patients had typical biliary pain at the time of laparoscopic procedure. Conclusions: The demand for LC from patients and practitioners is becoming increasingly more frequent, as all become aware of its benefits. However, on the basis of data from the literature and this study, the authors would like to emphasize the need for careful history-taking, thorough investigation, and comparison with gallstone symptoms before LC is performed. It is emphasized, however, that surgeons using laparoscopic approaches should learn techniques of full diagnostic laparoscopy, which should be performed at the beginning of every procedure.     

Gallstone ileus: An analysis of 20 patients

An analysis of 20 patients with gallstone ileus treated at the University Hospital in Linköping during a 10-year period is presented. The patients had a median age of 75 years and 70% were women. The symptomatology was usually vague and consisted of diffuse abdominal pain, often accompanied by vomiting. The delay before admission to the hospital averaged 4 days. Radiography with both plain abdominal x-rays and a barium meal showed mechanical intestinal obstruction in all but 1 patient and gallstone ileus was diagnosed before laparotomy in 60% of patients. Enterolithotomy was performed in all patients but there was no surgery on the gallbladder and/or the fistula. The frequency of postoperative wound infection was 25%. There was only 1 death, a mortality rate of 5%. It is our opinion that the low mortality was due to early diagnoses, careful preoperative preparation, an operative procedure aiming only at relief of the obstruction, and improved anesthesia and prophylactive short-term antibiotics. The only indication for an elective cholecystectomy is persistent symptoms of gallbladder disease.