From the Research
Enterolithotomy alone is the recommended surgical approach for gallstone ileus, as it is associated with lower morbidity and mortality, especially in high-risk elderly patients. Gallstone ileus is a rare complication of cholelithiasis, accounting for 1-4% of all small bowel obstructions, and predominantly affects elderly patients with a female predominance 1. The classic clinical presentation includes symptoms of bowel obstruction, such as abdominal pain, nausea, vomiting, and abdominal distension. Diagnosis typically requires imaging studies, with CT scan being the most sensitive modality, demonstrating Rigler's triad: pneumobilia, small bowel obstruction, and an ectopic gallstone.
Key Considerations
- The decision to perform a one-stage procedure (enterolithotomy plus cholecystectomy and fistula repair) versus enterolithotomy alone depends on the patient's condition and surgical risk.
- For high-risk elderly patients, enterolithotomy alone is often preferred as it carries lower morbidity and mortality 2.
- Postoperative care includes bowel rest, intravenous fluids, pain management, and monitoring for complications such as wound infection, anastomotic leak, or recurrent obstruction.
- The mortality rate remains relatively high (6.67-27%) due to the advanced age and comorbidities of affected patients, as well as the emergency nature of the surgery 1, 3.
Recent Evidence
A recent study published in 2022 found that enterolithotomy alone is a safe and effective technique, and urgent or delayed cholecystectomy is not necessary in most cases 2. Another study published in 2024 highlighted the importance of considering recurrent gallstone ileus in the management of patients with gallstone ileus, and the need for a comprehensive surgical approach to prevent recurrence 3. However, the most recent and highest quality study 2 supports the use of enterolithotomy alone as the primary surgical approach for gallstone ileus.
Surgical Approach
The surgical approach for gallstone ileus should prioritize minimizing morbidity and mortality, especially in high-risk elderly patients. Enterolithotomy alone is the recommended surgical approach, as it is associated with lower morbidity and mortality compared to more invasive techniques 1, 2.