What is the recommended surgical treatment for gallstone ileus?

Surgical Treatment of Gallstone Ileus

Enterolithotomy alone (simple stone extraction) is the recommended surgical treatment for gallstone ileus as it is associated with lower mortality and complication rates compared to more extensive procedures. 1

Understanding Gallstone Ileus

Gallstone ileus is an uncommon complication of cholelithiasis where a gallstone migrates through a bilioenteric fistula (typically cholecystoduodenal) and causes mechanical bowel obstruction. This condition primarily affects elderly females and requires prompt surgical intervention to relieve the obstruction.

Surgical Options

There are four main surgical approaches for gallstone ileus:

1. Enterolithotomy alone (ES) - Simple extraction of the stone through an enterotomy
2. Enterolithotomy with cholecystectomy and fistula closure (EF) - One-stage procedure
3. Bowel resection alone (BR) - When bowel viability is compromised
4. Bowel resection with fistula closure (BF) - Combined approach

Evidence-Based Recommendation

Nationwide data analysis shows that enterolithotomy alone is:

• The most commonly performed procedure (62% of cases) 1
• Associated with significantly lower mortality compared to EF and BR approaches 1
• The quickest procedure with shorter operative times 2

Surgical Approach Selection Algorithm

1. First priority: Relieve intestinal obstruction

   • Enterolithotomy with stone extraction is the primary intervention

2. Assessment factors:

   • Patient's clinical condition (ASA status)
   • Presence of shock or severe comorbidities
   • Bowel viability at the obstruction site

3. Decision tree:

   • If bowel is viable → Enterolithotomy alone
   • If bowel is compromised → Bowel resection
   • If patient is young, healthy, with good cardiorespiratory reserve → Consider one-stage procedure only in select cases 3

Minimally Invasive Options

When technically feasible and surgeon expertise allows:

• Laparoscopic enterolithotomy can be performed with potential benefits for postoperative recovery 4
• In select cases where the stone is accessible endoscopically (particularly colonic stones), electrohydraulic lithotripsy may be considered 5

Key Considerations and Pitfalls

• Avoid complex procedures in high-risk patients: One-stage procedures (EF) have 2.86 times higher mortality risk compared to enterolithotomy alone 1
• Bowel resection carries higher risks: BR is associated with 2.96 times higher mortality and 1.98 times higher complication rates than enterolithotomy alone 1
• Delayed cholecystectomy: The need for subsequent biliary surgery is low as most remnant fistulas do not lead to further complications 2
• Preoperative diagnosis: Often challenging and made in less than 50% of cases 2, requiring high clinical suspicion

Conclusion for Clinical Practice

For most patients with gallstone ileus, especially elderly patients with comorbidities, enterolithotomy alone should be the procedure of choice. The focus should be on relieving the obstruction with minimal operative trauma. One-stage procedures should be reserved only for young, stable patients with good physiologic reserve and minimal comorbidities.