Gallstone Ileus: Laparoscopic-Assisted Enterolithotomy

Singapore medical journal, 2004

Debate currently exists regarding the appropriate surgical strategy for emergency treatment of gallstone ileus. This relates to the need for definitive biliary tract surgery after relief of mechanical obstruction. Our study reviews treatment by enterolithotomy alone and enterolithotomy combined with definitive biliary tract surgery and fistula closure to determine if there is advantage of one treatment option over the other. The clinical, operative and follow-up data on 19 consecutive patients treated by emergency surgery for gallstone ileus from January 1992 to December 2000 was retrospectively reviewed. There were 15 women and four men, with a mean age of 74.6 (range 62-91) years. Pre-operative diagnosis was made in only nine of 19 patients. Enterolithotomy alone (E group) was performed in seven patients and enterolithotomy with cholecystectomy and fistula closure (E+C group) in 12 patients. In the E group, more patients had significant co-morbidity as identified by poorer America...

JSLS, Journal of the Society of Laparoendoscopic Surgeons, 2010

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.

Surgery Case Reports

Gallstone ileus is a rare complication of cholelithiasis which represent 1-3% of the causes of intestinal obstruction in the general population and is more commonly seen in females. Gallstone ileus does not present with unique symptoms, making the diagnosis difficult. Symptoms are often non-specific with intermittent intestinal obstruction. The management is surgical, but there is no consensus as to which of the different surgical techniques is the procedure of choice. We report an interesting case of a 78-year-old male brought to casualty with abdominal pain following a history of fall. Managed as a case of blunt trauma abdomen initially. Surprisingly investigations showed features of small bowel obstruction, a hyperdense structure in the distal jejunum with dilated proximal jejunal loops suggestive of gallstone ileus. The patient had undergone exploratory laparotomy with enterotomy and removal of gallstones without any postoperative complications. Intraoperatively cholecystoduoden...

Journal Current Surgery, 2012

Background: The typical patient with Gallstone ileus is female, elderly, with concomitant medical diseases and high operative risk. This disease is becoming more common as a result of increase the aging population. Its diagnosis is difficult and early diagnosis could reduce the mortality. Nowadays the use of new imaging techniques can expedite the correct diagnosis, decreasing preoperative delay. However, controversy persists primarily in relation to surgical strat-egy. Methods: We retrospectively reviewed the medical records of all patients with the diagnosis of intestinal obstruction between 1998 and 2011. We took into consideration concomitant medical conditions, previous history of cholelithiasis, operative risk (ASA score), preoperative findings, duration and type of surgery, post-operative outcome, 30-day mortality. Results: The incidence was 0.66% (4 out of 601 cases of intestinal obstruction), 1% if we consider small bowel obstruction only (399 cases), 2.01% in patients over the age of 65 (199 out of 601) and 3.73 % in patients over the age of 80 (107 out of 601). In cases of small bowel obstruction resulting in impacted foreign body the incidence was 36.36 %. All patients were female with a mean age of 81.7 (range 75 - 86). The proper diagnosis prior to surgery was assessed in 2 out of 4 cases. In one case enterolithotomy was completed in one stage with cholecystectomy and closure of the fistula during acute surgery, while in 3 cases enterolithotomy alone was performed, 1 patient operated enterolithotomy alone died on the 14th postoperative. Conclusions: The history, clinical, and radiologic findings are often nonspecific suggesting only a small bowel obstruction. Nowadays the use of new imaging techniques, in combination with plain abdominal radiographs, can expedite the correct diagnosis in over 50% of cases decreasing preoperative delay. The type of intervention does not significantly influence post-operative morbidity and mortality rates. We believe to perform simple enterolithotomy as procedure of choice, while the one-stage procedure should be performed in patients with greater life expectancy, less operative risk and comorbidity.

Journal of Gastrointestinal Surgery, 2015

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.

INTRODUCTION: Gallstone ileus is a rare complication of cholelithiasis leading to small intestinal obstruction. Elderly females are commonly affected more than male. The diagnosis of this condition is challenging and Rigler's triad is pathognomonic. Surgery is mandatory with no clear consensus about the best surgical approach that should be adopted. CASE PRESENTATION: An elderly female patient, with no previous history of biliary diseases, presented with small bowel obstruction. Contrast enhanced computed tomography of the abdomen showed the classical Rigler's triad. Total laparoscopic enterolithotomy was performed successfully. She had smooth postoperative course and she was followed up regularly without occurrence of any biliary disease symptoms during the follow up period. CONCLUSION: Gallstone ileus should be considered in differential diagnosis of small bowel obstruction mainly in old females with no previous history of abdominal surgery. Laparoscopic enterolithotomy is safe, feasible and effective when performed by experienced surgeons.

Clinical Medicine Insights: Case Reports, 2014

Gallstone ileus is a rare complication of cholelithiasis that has high morbidity and mortality. An intestinal obstruction can be caused by migration of a large gallstone through a biliary enteric fistula or by impaction within the intestinal tract. In this study, we present the case of an 81-year-old woman with a mechanical bowel obstruction by a gallstone that was treated by laparoscopy. CITaTIon: Bircan et al. laparoscopic treatment of gallstone ileus.

Singapore Med J, 2008

Introduction: Gallstone ileus is responsible for 1-3 percent of cases of mechanical small bowel obstruction. Debate continues regarding choice of optimal surgical procedure. One-stage procedure includes enterolithotomy, cholecystectomy and repair of fistula at the same setting, whereas staged procedure includes enterolithotomy alone, with fistula repair at a later stage. This study aims to determine factors influencing choice of surgical procedure in patients with gallstone ileus. Methods : Data was collected for patients diagnosed with gallstone ileus between 1990 and 2005. Five patients underwent enterolithotomy alone (Group 1), while the remaining f ive patients under went enterolithotomy with cholecystectomy and repair of fistula as a single stage procedure (Group 2). Results : In Group 1, patients presented late with deranged physiological parameters and pre-existing comorbidities accounting for an American Society of Anesthesiologists (ASA) score of 3 or above. In Group 2, patients presented early with preserved physiological status accounting for an ASA score of 2. The mean operative time was 126 +/-23 minutes in Group 1 and 245 +/-54.4 minutes in Group 2. There was no mortality, three patients in Group 1 had superficial wound infection, and one patient in Group 2 had injury to the common bile duct necessitating hepaticojejunostomy. The mean follow-up period was 3.5 +/-1.5 years. None of the patients in both groups had recurrent symptoms requiring further intervention. Conclusion: Choice of surgical procedure was largely determined by the clinical status of the patient. Single-stage procedure was performed in haemodynamically-stable patients, while enterolithotomy alone was considered sufficient for unstable patients.

BMJ Case Reports, 2019

Although gallstone disease is classically associated with the inflammatory sequela of cholecystitis, other presentations include gallstone ileus, Mirizzi syndrome, Bouveret syndrome and gallstone ileus. Gallstone ileus occurs when a gallstone passes from a cholecystoduodenal fistula into the gastrointestinal tract and causes obstruction, usually at the ileocaecal valve. It represents an uncommon complication of cholelithiasis, accounting for 1%–4% of all cases of mechanical bowel obstruction and 25% of all cases in individuals aged >65 years. It has a female predilection. Clinical presentation depends on the site of the obstruction. Diagnosis can prove challenging with the diagnosis rendered in 50% of cases intraoperatively. The authors present the case of a 79-year-old woman with a 10-day history of abdominal pain, nausea, vomiting and episodes of loose stools. An abdominal radiograph showed mildly distended right small bowel loops. Further investigation with a CT of the abdomen...

Annals of Surgery, 2014

Introduction: Gallstone ileus is a mechanical bowel obstruction caused by a biliary calculus originating from a bilioenteric fistula. Because of the limited number of reported cases, the optimal surgical method of treatment has been the subject of ongoing debate. Methods: A retrospective review of the Nationwide Inpatient Sample from 2004 to 2009 was performed for gallstone ileus cases treated surgically by enterotomy with stone extraction alone (ES), enterotomy and cholecystectomy with fistula closure (EF), bowel resection alone (BR), and bowel resectionwith fistula closure (BF). Patient demographics, hospital factors, comorbidities, and postoperative outcomes were reported. Multivariate analysis was performed comparing mortality, morbidity, length of stay, and total cost for the different procedure types. Results: Of the estimated 3,452,536 cases of mechanical bowel obstruction from 2004 to 2009, 3268 (0.095%) were due to gallstone ileus-an incidence lower than previously reported. The majority of patients were elderly women (>70%). ES was the most commonly performed procedure (62% of patients) followed by EF (19% of cases). In 19%, a bowel resection was required. The most common complication was acute renal failure (30.44% of cases). In-hospital mortality was 6.67%. On multivariate analysis, EF and BR were independently associated with higher mortality than ES [(odds ratio [OR] = 2.86; confidence interval [CI]: 1.16-7.07) and (OR = 2.96; CI: 1.26-6.96) respectively]. BR was also associated with a higher complication rate, OR = 1.98 (CI: 1.13-3.46). Conclusions: Gallstone ileus is a rare surgical disease affecting mainly the elderly female population. Mortality rates appear to be lower than previously reported in the literature. Enterotomy with stone extraction alone appears to be associated with better outcomes than more invasive techniques. Gallstone ileus is a mechanical bowel obstruction due to intraluminal intestinal occlusion by a biliary calculus. 1,2 This condition occurs when an inflamed gallbladder adheres to adjacent bowel forming a biliary-enteric fistula, which can allow gallstones to enter the gastrointestinal tract. 3-5 Although 25% to 72% of patients with gallstone ileus have a known history of cholelithiasis, 6-10 only 0.3% to 1.5% of patients with cholelithiasis will develop gallstone ileus. 2,7,11 It has previously been estimated that 1% to 5% of all cases of bowel obstruction are caused by this condition. 1,6,8,12,13 The cornerstone of gallstone ileus management is surgery. Enterotomy with stone extraction should be performed urgently to relieve the obstruction. In some instances, firmly impacted stones can cause localized bowel necrosis, making segmental resection necessary. 4,12,14,15 However, there has been debate on whether the cholecystoenteric fistula should be approached during the initial procedure. 3,16