CIRUGIA Y CIRUJANOS

ARTÍCULO ORIGINAL

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Comparison between surgical techniques in gallstone ileus and
outcomes
Comparación de técnicas quirúrgicas en el íleo biliar y sus resultados
Abner A. Requena-López*, Brenda K. Mata-Samperio, Fernando Solís-Almanza, Ricardo Casillas-Vargas
y Luis A. Cuadra-Reyes
Departamento de Cirugía General, Centro Médico Instituto de Seguridad Social del Estado de México (ISSEMyM), Ecatepec, Estado de México, México

Abstract

Introduction: Gallstone ileus is a rare cause of mechanical bowel obstruction, generally found in elderly patients who often have
other significant medical conditions. Objective: The objective of the study was to determine the prevalence of gallstone ileus and
the number of postsurgical complications and outcomes depending on what type of surgical management is performed. Method: Co-
hort, retrospective, observational, and comparative study was conducted, which included 31 patients undergoing surgery for gall-
stone ileus. Three groups were integrated according to the type of surgical procedure: Group 1: enterotomy and stone extraction
alone,. Group 2: enterotomy and cholecystectomy with fistula closure, and Group 3: bowel resection alone. Results: A total of
31 patients were analyzed. Gallstone ileus represented the 1.44% of all cases of bowel obstruction. Complication rates were
similar between three groups. Mortality rate was lower in Group A, especially when compared to Group B, with a statistically sig-
nificant difference (p < 0.05). Conclusions: Surgery is the pillar in treatment of gallstone ileus. Enterotomy with stone extraction
alone appears to be associated with a lower mortality rate and better outcomes when compared to more extensive techniques.

Key Words: Gallstone ileus. Surgery. Mortality. Bowel obstruction. Bilioenteric fistula.

Resumen

Antecedentes: El íleo biliar es una causa rara de obstrucción intestinal mecánica, que se presenta generalmente en pacien-
tes ancianos que a menudo tienen otras afecciones médicas importantes. Objetivo: Determinar la prevalencia del íleo biliar,
el número de complicaciones y los resultados según el tipo de tratamiento quirúrgico que se realice. Método: Estudio de
cohorte, retrospectivo, observacional y comparativo, que incluyó 31 pacientes sometidos a cirugía por íleo biliar. Se integra-
ron tres grupos según el tipo de procedimiento quirúrgico: grupo 1, enterotomía y extracción de cálculos únicamente; grupo
2, enterotomía y colecistectomía con cierre de fístula; y grupo 3, resección intestinal únicamente. Resultados: Se analizaron
31 pacientes. El íleo biliar representó el 1.44% de todos los casos de obstrucción intestinal. Las tasas de complicaciones
fueron similares en los tres grupos. La tasa de mortalidad fue menor en el grupo 1, en especial cuando se comparó con el
grupo 2, con una diferencia estadísticamente significativa (p < 0.05). Conclusiones: La cirugía es el pilar en el tratamiento
del íleo biliar. La enterotomía con extracción de cálculos parece asociarse con una menor tasa de mortalidad y mejores
resultados en comparación con técnicas más extensas.

Palabras Clave: Íleo biliar. Cirugía. Mortalidad. Obstrucción intestinal. Fístula bilioentérica.

Correspondencia:
*Abner A. Requena López
Avda. Del trabajo, s/n
Col. El Carmen, Del. Ecatepec de Morelos Fecha de recepción: 29-04-2019 Cir Cir. 2020;88(3):292-296
C.P. 55000, Estado de México, México Fecha de aceptación: 06-09-2019 Contents available at PubMed
E-mail: [email protected] DOI: 10.24875/CIRU.19001264 www.cirugiaycirujanos.com
0009-7411/© 2019 Academia Mexicana de Cirugía. Publicado por Permanyer. Este es un artículo open access bajo la licencia CC BY-NC-ND
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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 A.A. Requena-López, et al.: Surgery in gallstone ileus

Introduction Table 1. General characteristics

Characteristics Group 1 Group 2 Group 3

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Gallstone ileus is a rare cause of mechanical bowel Sex
Female 16 5 3
obstruction, generally found in elderly patients who
Male 4 1 2
often have other significant medical conditions. It oc-
curs in the setting of chronic cholecystitis when de Mean age 68.7 70.2 65.9

impacted gallstone erodes into the adjacent duode- Weight (kg) 70.1 ± 5.5 68.1 ± 4.5 69 ± 5.2
num, producing a cholecystoenteric fistula most com- Hospital stay (days) 12 14 13
monly, although it also can be a cholecystogastric or
cholecystocolonic fistula. Then, the gallstone passes
Table 2. Comparison of comorbidities and comorbidity scores
down through the gastrointestinal tract until it reaches between groups
the distal ileum causing obstruction1.
Comorbidities Group 1 Group 2 Group 3
(n = 20) (n = 6) (n = 5)
Objective
Diabetes 12 (60%) 4 (66.6%) 2 (40%)

The objective of the study was to determine the Hypertension 10 (50%) 2 (30%) 1 (40%)
prevalence of gallstone ileus and the number of post- Chronic kidney disease 6 (30%) 1 (16.6%) 1 (20%)
surgical complications and outcomes depending on
Congestive heart failure 4 (20%) 0 0
what type of surgical management is performed: en-
terotomy with stone extraction alone (EE), enterotomy Chronic pulmonary disease 6 (30%) 1 (16.6%) 1 (20%)
and cholecystectomy with fistula closure (enterocuta- Comorbidity score with adjusted age** 6 (3‑9) 4 (3‑8) 5 (3‑6)
neous fistula [ECF]), and bowel resection (BR).
Total comorbidities per group 38 8 5
**Comorbidity scores are based on the Charlson comorbidity index
Method
qualitative variables by frequency and percentage.
Cohort, retrospective, and observational study was Statistical analysis was performed using the IBM
conducted. We included all those patients diagnosed SPSS Statistics 24.0 software. A reliability of 95% was
with gallstone ileus that underwent exploratory lapa- granted and it was considered p < 0.05 as statistically
rotomy at our unit in a time lapse of 16 years from significant.
January 1, 2003, to December 31, 2018. Data were
collected from the physical and electronic files. A total Results
of 31 patients were diagnosed with gallstone ileus
over this period of time. According to the surgical pro- During this period, 2138 cases of bowel obstruction
cedure, we integrated three different groups: Group 1: were registered and only 31 (1.44%) were due to gall-
patients who underwent enterotomy and stone extrac- stone ileus. Patients in this study were mostly elderly,
tion alone, Group 2: patients who underwent enter- with a median age of 67 years (62-78), with females
otomy and cholecystectomy with fistula closure, and accounting for the vast majority of patients, 24 (77.41%)
Group 3: patients who underwent BR alone without of which were women and 7 (22.58%) men. General
fistula closure. characteristics, including weight and hospital stay, are
Factors such as sex, age, and length of hospital summarized in table 1.
stay were evaluated and placed into a database. Mul- All patients were treated surgically, three procedures
tivariate logistic regression was used to compare mor- were performed. The most common was Stone Extrac-
tality and morbidity between groups after controlling tion (SE) with 20 cases, followed by ECF closure, and
for age, gender, surgery type Stone Extraction, En- finally BR with 6 and 5 cases, respectively.
terocutaneous fistula or Bowel Resection (SE, ECF or All patients had at least one comorbidity, some pa-
BR), and comorbid conditions. The presence or ab- tients had even 4-5 comorbidities, comorbidity scores
sence of post-operative complications from the im- ranged from 3 to 9. Results, including comorbidity
mediate post-operative period was determined in each scores, are summarized in table 2.
group, with a follow-up of 6 months. The quantitative Regarding clinical manifestations the most common
variables were defined by the median and the were abdominal pain and vomit, presenting in all
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Table 3. Clinical manifestations Table 5. Comparison of mortality rates

Clinical manifestations Number of cases (%) Groups Mortality

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Abdominal pain 31 (100) Group 1 2 (10%)

Vomit 31 (100) Group 2 2 (33.3%)

Abdominal distention 18 (58) Group 3 1 (20%)

P1 0.042
Constipation 16 (51.6) P2 0.72
P3 0.95
Anorexia 10 (32.2)
P1: Group 1 versus Group 2; P2: Group 1 versus Group 3; P3: Group 2 versus
Group 3; (p < 0.05) statistically significant.

Table 4. Comparison of complications between groups belonging to Group 1. Two patients had cardiac com-
Complications Group 1 Group 2 Group 3 P1 P2 P3 plications, they belonged to Group 1 and Group 2. The
(n = 20) (n = 6) (n = 5) value value value results are summarized in table 4.
(%) (%) (%)
Finally, mortality rates vary between all groups. The
Anastomotic 2 (10) 2 (33.3) 1 (20) 0.073 0.15 0.24 highest rate was observed in Group 2, with 2 fatal
leak or
abscess
cases representing 33.33%. Group 1 had a mortality
rate of 5%, corresponding to 1 patient and Group 3 had
Bleeding 1 (5) 0 0 0.08 0.08 0.72
a mortality rate of 20%, corresponding also to 1 pa-
Cardiac 1 (5) 1 (16.6) 0 0.09 0.68 0.09 tient. We observed a total mortality rate of 12.9%. The
complications mortality rate in Group 1 was lower in comparison with
Pneumonia 2 (10) 1 (16.6) 1 (20) 0.07 0.08 0.25 the other two groups; however, a statistically significant
Acute renal 3 (15) 1 (16.6) 1 (20) 0.09 0.12 0.65
difference was only observed when comparing enter-
failure otomy with gallstone extraction alone with enterotomy
and cholecystectomy with fistula closure (p < 0.05). A
Wound 2 (10) 1 (16.6) 1 (20) 0.07 0.09 0.55
complications comparison of mortality rates is summarized in table 5.
Total 11 (55) 6 (100) 4 (80) 0.09 0.26 0.81
Discussion
P1: comparison between EE and ECF; P2: comparison between EE and BR;
P3: comparison between ECF and BR.
(p < 0.05 statistically significant).
ECF: enterocutaneous fistula; BR: bowel resection.
Gallstone ileus is an unusual complication of chole-
lithiasis and represents a small percentage of me-
chanical small bowel obstruction cases2. It is caused
patients. The second most common manifestations by the passage of a stone through a fistula, which can
were abdominal distention and constipation that were be cholecystoenteric, accounting for approximately
present in 50-60% of the cases. All clinical manifesta- 60% of all cases followed by cholecystogastric or
tions are summarized in table 3. cholecystocolonic1,3.
The diagnosis was made by abdomen radiographs Over the past 50 years, gallstone ileus was attrib-
in 10 patients (32.25%), computed tomography (CT) uted to be the cause in 1-5% of mechanical bowel
was required in 15 cases (48.38%) and in 6 patients obstructions3-5. However, only 1001 cases were re-
(19.35%), the diagnosis of gallbladder ileus was made ported in the United States in the past century6. On
intraoperatively. the other hand, the data collected by Halabi et al.
The fistula encountered intraoperatively was cholecys- revealed that from 2004 to 2009, an estimated
toenteric in 23 cases (74.19%), cholecystogastric in 7 cas- 3268 patients underwent surgery for gallstone ileus in
es (22.58%), and cholecystocolonic in 1 case (3.22%). the United States. Although the number of cases in
We found no statistically significant difference in this time lapse of 6 years was more than the triple of
complications rates between groups, the most com- the cases reported over the last century, it actually
mon complications were anastomotic leak/intraab- accounts only for 0.095% of mechanical bowel ob-
dominal abscess and acute renal failure, which were struction in that country, a much lower percentage
present in 10 patients (32.25%), followed by pneumo- than previously thought 2. Unfortunately, in Mexico,
nia and wound complications, with 4 cases each there is no precise registry to determine the correct
(25.8%). Bleeding was seen only in one patient incidence or prevalence of this entity.
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The fistula formation in this disease probably follows

this sequence. Repeated cholecystitis and perichole-
cystic inflammation produce adhesions between the

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biliary and enteric systems. Then, the gallstone press-
es the biliary or enteric wall causing erosion and fistula
formation1. Furthermore, cases of gallstone ileus follow-
ing endoscopic sphincterotomy have been reported7.
The obstruction is produced depending on the gall-
stone size. More than 90% of obstructing gallstones
are > 2 cm, the majority measuring over 2.5 cm8.
Approximately 70% of gallstones impact at the ile-
um, corresponding to the narrowest segment of the
intestine. The second and third sites in order of fre-
quency are jejunum and stomach, respectively 9.
The classic clinical picture of gallstone ileus is an Figure 1. Plain abdominal film showing a foreign body in the right
elderly woman with episodic subacute obstruction. lower abdomen (arrows) and some distension of bowel loops.
The episodic obstruction is produced by the stone
tumbling through the bowel lumen. Transient gallstone
impaction produces diffuse abdominal pain and vomit-
ing, which subside as the gallstone becomes disim-
pacted, only to recur again as the stone lodges in the
more distal bowel lumen. This results in vague and
intermittent symptoms that generally are present for
some days before hospital admission, the mean
symptom duration before this is approximately 5 days3.
Gallstone ileus should be suspected in elderly pa-
tients, especially women, with a clinical picture of
acute or subacute small bowel obstruction, it can be
confirmed by either radiologic evaluation or, in some
Figure 2. Abdominal computed tomography scan image demonstrat-
cases, intraoperatively1. ing an obstructing, calcified intraluminal stone. Evidence of small
With the current usage of modern radiologic tests, bowel obstruction noted with dilated loops proximal to the obstruction.
especially the CT, diagnosis can be made in 77% of
patients preoperatively, in contrast with other radio- gallstone (usually in the iliac fossa) but is seen only
logic tests used in the past, where > 1½ of the patients in approximately 25% of cases11.
were diagnosed before surgery (Fig. 1)3,9. The treatment for gallstone ileus is primarily surgi-
The imaging modality of choice for gallstone ileus cal. Gallstone ileus involves three key elements cho-
is the abdominal CT (Fig. 2). The radiologic findings lelithiasis, biliary-enteric fistula, and bowel obstruction.
consistent with gallstone ileus include gallbladder wall The latter is typically addressed with an enterotomy
thickening, pneumobilia, bowel obstruction, and ob- with stone removal. Cholelithiasis and biliary-enteric
structing gallstones10. fistula are typically addressed by cholecystectomy
Due to the limited availability of CT, surgeons may and fistula closure1.
make use of other diagnostic tests, plain films and The majority of patients with gallstone ileus are typi-
ultrasound may be helpful in these cases. The classic cally treated with an open enterolithotomy first. A lon-
findings of gallstone ileus on a plain abdominal film gitudinal enterotomy is made along the antimesenteric
include signs of partial or complete bowel obstruction, border proximal to the point of impactation12. The
pneumobilia, visualization of the gallstone, and change stone is extracted proximally and removed. A trans-
in the position of a previously located stone. Two of verse closure of the enterotomy is made to avoid re-
the first three findings were found in up to 50% of sidual bowel stenosis. If the cecum is manipulated in
cases of gallstone ileus in one study. On the other the presence of stones, it can produce mucosal injury
hand, Rigler’s triad is the appearance on plain radio- and undetected serosal rupture and therefore should
graph of pneumobilia, small bowel obstruction, and not be performed routinely3.
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The entire bowel should be inspected for more which ranged between 5 and 13%2. The lowest mortality
­gallstones, it has been reported that multiple gallstones rate was seen in patients that underwent enterolithotomy
are present in up to 16% of cases. In some cases, only when compared to the other two techniques; it was

Sin contar con el consentimiento previo por escrito del editor, no podrá reproducirse ni fotocopiarse ninguna parte de esta publicación.   © Permanyer 2020
gallstones are cylindrical and are associated with an only statistically significant when compared to enteroto-
increased likelihood of multiple stones present13. The my and cholecystectomy with fistula closure. Hence, we
majority of cases of recurrent gallstone ileus are pre- recommend that the latter should be undertaken in high-
sumably due to cylindrical stones missed at initial ly selected patients, and only on an elective basis.
operation14.
In high-risk patients (multiple comorbidities, shock, Conflicts of interest
or significant intra-abdominal inflammation or adhe-
sions), enterolithotomy followed by close observation The authors declare no conflicts of interest.
is highly recommended15,16.
Expectant management after enterolithotomy is Ethical disclosures
completely justified and it has been observed that
biliary-enteric fistulas may close or shrink spontane- Protection of human and animal subjects. The
ously, especially with a patent cystic duct and the authors declare that no experiments were performed
absence of residual stones6,16. on humans or animals for this study.
Enterolithotomy with a definitive biliary surgery as a Confidentiality of data. The authors declare that
one-stage procedure can be done in low-risk patients. they have followed the protocols of their work center
Advantages of the one-stage procedure include a re- on the publication of patient data.
duced recurrence of gallstone ileus, also prevent mal- Right to privacy and informed consent. The au-
absorption and weight loss from persistent fistula, and thors have obtained the written informed consent of the
prevent cholecystitis, cholangitis, and gallbladder carci- patients or subjects mentioned in the article. The cor-
noma; however, it has higher morbidity and mortality3. responding author is in possession of this document.

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