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Evaluation and surgical management of the gallstone ileus. A single center experience
M. Safioleas, M. Stamatakos, C. Spyrakos, P. Safioleas, C. Chatzikonstantinou, R. Iannescu, C. Safioleas (Chirurgia, 103 (3): 301-304)

Introduction
Gallstone ileus is a rare complication of cholelithiasis representing 1% to 4% of all intestinal obstructions (1-5). It occurs predominantly in the elderly where it accounts for about 25% of all non-strangulated mechanical obstructions of the small intestine. Gallstones enter the gastrointestinal tract usually through a fistula and 80-90% of them pass spontaneously (6, 7). Impaction of one or more gallstone in the lumen of the bowel is a surgical emergency. Relief of the obstruction is the treatment of choice but controversy exists regarding the repair of the fistula and cholecystectomy. The purpose of this study is to present our experience in the management of gallstone ileus and to review the therapeutic approaches.

Material and Methods
During the period 1970 - 2004, in thirty-six patients the operative finding was gallstone ileus. The age of the patients ranged from 56 to 87 years old (mean age 72.5). Twenty-seven patients were females and 9 were males (male:female ratio 1:4). In twenty-two patients the preoperative diagnosis was obstructive ileus or acute abdomen. The diagnosis of gallstone ileus was established preoperatively in 14 patients. All the patients presented with diffuse colicky abdominal pain, nausea and vomiting. Twenty patients had a history of cholecystopathy. Plain abdominal radiograph in erect position was performed in all the patients at the time of admission. Computed tomography was performed in the last 8 patients. Following admission, nasogastric tube for bowel decompression was introduced to all patients and dehydration and electrolyte disturbances were corrected.
Enterolithotomy alone was performed in 28 patients. In 8 patients a one stage procedure (enterolithotomy plus fistula repair and cholecystectomy) was performed.
The postoperative complications were wound infection in 6 patients, incomplete ileus in 2 patients and obstructive ileus due to adhesions in 1 patient who was re-operated. There were no deaths in our series. The postoperative hospital stay ranged from 8 to 18 days (mean 12 days).
All the patients were followed postoperatively for a period ranging from 12 to 16 months.

Figure 1

Discussion
Gallstone ileus is a rare cause of mechanical obstruction of the bowel. It was first described by Bartholin in 1654 and it was an autopsy finding. It has been reported an increase in its incidence as result of the demographic changes.
Gallstones pass into the gastrointestinal tract in less than 1% of the patients with cholelithiasis and 80-90% of them will be defecated. In very rare cases they may be vomited. The gallstone usually enters the gastrointestinal tract through a biliary-enteric fistula or through the common bile duct and the papilla of Vater (8). The bilary fistula may be internal, communicating with the intestinal tract or external ending in other neighbouring organs. Cholecystoduodenal fistulas are the most common fistulas. Depending on the extend of inflammation fistulas may develop between the gallbladder and the stomach, jejunum, ileum, colon, bronchus, renal pelvis and urinary bladder (7). Most fistulas close spontaneously after the passage of the stone. Preoperative visualization of the fistula does not add in the management of these patients. Obstruction is caused by gallstone with a diameter at least 2.5 cm (9, 10). The transit time may from several days up to four years (11).
The preoperative diagnosis of gallstone ileus is difficult. Approximately 1/3 of the patients has no history of previous biliary symptoms. The delay in diagnosis is attributed to the intermittent nature of the symptoms and the concomitant dehydration and electrolyte imbalance (12). This so-called tumbling phenomenon is caused by the distal migration of the gallstone (3). The tumbling phenomenon caused by migration The patients may have mild symptoms for several days or may pass flatus if the obstruction is not complete. Often abdominal radiograph has no diagnostic features. The classic Rigler's triad (small bowel obstruction, pneumobilia and presence of calcified bone) was identified in 5 patients. Gallstones are often radioluscent and small bowel loops are not dilated until the stone is firmly impacted causing edema of the damaged mucosa and making the obstruction complete.
Axial computed tomography was performed in 8 patients and showed the calcified stone in all the cases. The gallstone may be impacted at any segment of the gastrointestinal tract from the gastric outlet, causing Bourevet's syndrome, up to the rectosigmoid (13, 14). Pneumobilia was present in 6 cases. Spontaneous closure of the fistula may have occurred in two patients. CT is a useful fast, widely available, non-invasive diagnostic tool for patients with abdominal pain of uncertain aetiology and has being increasingly used in the diagnosis of small bowel obstruction (15). Rigler's triad can be identified, the site of obstruction, the size of the stone and the presence of a second gallstone can be determined allowing the accurate surgical planning for laparotomy or minimal invasive techniques (16, 17). For gallstones with a diameter less than 2.0 cm spontaneous evacuation may occur (16). CT scan is also important if the stone is located in a congenital or acquired diverticulum since gallstone have been found in the neck a Meckel's diverticulum (18) and in diverticuli of the recto-sigmoid. The site of gallstone impaction in our series was in the terminal ileus in 29 patients, in the duodenum in 6 patients and in the transverse colon in 1 patient.
There are large published series suggesting either enterolithotomy alone or enterolithotomy plus fistula repair and cholecystectomy as the procedure of choice for patients with gallstone ileus (19-21). In our series the therapeutic approach was dictated by the age of the patient, the size of the stone and the presence of concomitant illnesses. The selected surgical procedure of choice should be the one with the least early or late complications. The presence of acute cholecystitis, gangrene of the gallbladder, residual stones or external fistula are the only absolute indications for fistula excision and clolecystectomy or cholecystostomy in patients with advanced age and concomitant illnesses. Otherwise simple enterotomy and extraction of the stone, either by laparotomy or minimal invasive techniques has the lowest morbidity and mortality. Cholecystectomy should also be performed in the younger patients because of the increased incidence of biliary carcinoma. Several studies have compared the simple enterolithotomy with the one stage repair which includes not only the relief of the obstruction but also repair of the fistula and cholecystectomy. A comparison of these two approaches is not feasible since there are not differences in the technique and both include enterolithotomy. The operative findings, the presence of gallstones and the age of the patient should dictate the approach. A more complicated operation in elderly patients may be associated by higher morbidity and mortality and should be performed in selected cases (22).
Removal of the stone without enterotomy can be performed by crushing of the stone and manual propulsion but only in highly selected cases since it may result in subserosal rupture of the intestinal wall (23). The gallstone may also be milked to the large bowel if it is not impacted firmly. Endoscopy, combined with mechanical, extracorpeal shock wave or laser lithotripsy if the stone is impacted, is useful for the removal of stones in the upper gastrointestinal tract or in the large bowel (24, 25). Complications associated with endoscopic removal include mucosa damage and perforation if the stone is large, fragmentation has not been attempted and the mucosa is friable or ulcerated. If the core of the stone is not completely fragmented and destruction is limited in the superficial layers the stone may migrate and obstruct a distal segment of the bowel. In such cases, since it can not be reached endoscopically urgent enterolithotomy is required (26).
Laparoscopy has certain advantages (27). The operative wound is minimal but there is a risk of missed pathology of other organs (28, 29).
The possible complications of unrepaired fistula, recurrent gallstone ileus and cholangitis, occur only if there are residual stones in the gallbladder or in the bile duct causing obstruction and stasis of the bile flow. In the absence of these the surgical approach should be limited to the relief of obstruction either by laparotomy either by minimal invasive techniques (30). The delay in diagnosis may be reduced by the use of computed tomography in cases of atypical, interminent abdominal pain in elderly.
In conclusion, for particular cases of unexpected obstructive ileus, such as patients without previous operation or patients without incarcerated hernias or obvious abdominal tumours, an index of suspicion should be reserved for the likelihood of a gallstone ileus.

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