Gallstone ileus

Thirty-seven patients (33 women and four men, median age 78 years) were operated on for gallstone ileus over a 12-year period with a median follow-up of 6.2 years. Twenty-three patients (62 per cent) had serious concomitant diseases. Plain abdominal radiographs performed at admission were diagnostic in only 17 patients (46 per cent) and other procedures such as ultrasonography, gastrointestinal contrast studies and computed tomographic scan were required in ten patients (27 per cent). The diagnosis was made before operation in 27 patients (73 per cent) but in only 17 (46 per cent) at admission. Obstructing stones were located in the terminal ileum in 27 patients (73 per cent), in the proximal ileum or jejunum in five (14 per cent), in the duodenum in two (5 per cent), and in the colon in three (8 per cent). In six instances (16 per cent), more than one stone was involved. Cholecystduodenal fistula was the most frequent fistula type (n = 25, 68 per cent), followed by cholecystcolonic (n = 2, 5 per cent) and cholecystduodenocolonic (n = 2, 5 per cent) types. The site of the fistula was not established in the other eight instances. A one-stage procedure consisting of the removal of the impacted stone, fistula repair and cholecystectomy was performed in eight patients, two of whom died. A second group of six patients underwent a two-stage procedure consisting of enterolithotomy followed by elective biliary surgery, with no mortality. Removal of impacted stones was the only surgical treatment in the remaining 23 patients, with five deaths. Operative mortality and morbidity rates associated with the initial procedure did not differ significantly among the three therapeutic groups, which were comparable in terms of patient age, associated concomitant diseases and APACHE II score. However, later biliary complications were prominent in patients treated only by enterolithotomy. These results support the view that a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. When local or surgical conditions argue against a one-stage procedure, biliary surgery at a second stage should be considered, if residual stones are present. In poor risk patients, non-operative methods should be considered.     

Gallstone ileus

Twenty patients with gallstone ileus were treated over a 20-year period. The demographics were typical: mean age 76, female to male ratio of 5:1, and 60 per cent incidence of concomitant medical ailments. An 85 per cent preoperative diagnostic rate was unusually high. An analysis of the study halves demonstrated a stable preoperative diagnostic rate, decrease in preoperative delay (7.5 vs. 4.7 days), and a rise in mortality rate (0 vs. 11%) without an unfavorable effect from a 26 per cent incidence of single-stage procedures (0% mortality). Gallstone ileus still carries a mortality rate of five to ten times that of all other nonmalignant mechanical small bowel obstructions. Anticipated improvements related to augmented preoperative diagnostic yields shortened preoperative delays, and selective surgical management have not been substantiated. Improved mortality rates may await refinements in resuscitation, monitoring, and surgical skills.     

Gallstone ileus

Aetiopathogenesis, diagnosis as well as typical and atypical courses are described and discussed with regard to 50 patients with gallstone ileus. Overall lethality amounted to 36 per cent, including 15 per cent for patients with enterotomy alone and 53 per cent for patients who had undergone enterotomy with faecal aspiration. Postoperative complications were recorded from 78 per cent of the survivors.