Management of Gallstone Ileus in an Elderly Patient
Enterolithotomy alone (option A) is the recommended management for an elderly patient with gallstone ileus presenting with intestinal obstruction and a stone in the terminal ileum. 1
Rationale for Enterolithotomy Alone
Gallstone ileus is a rare complication of cholelithiasis that causes mechanical intestinal obstruction due to impaction of gallstones in the gastrointestinal tract. The condition carries significant morbidity (20-40%) and mortality (1.3-4%), particularly in elderly patients 2.
The surgical management options include:
- Enterolithotomy alone - Simple removal of the obstructing stone
- One-stage procedure - Enterolithotomy plus cholecystoduodenal fistula repair and cholecystectomy
- Stone crushing - Less commonly performed
Why Enterolithotomy Alone is Preferred in Elderly Patients:
- Lower surgical risk: Enterolithotomy alone is associated with lower morbidity in high-risk elderly patients 1
- Shorter operative time: Reduces anesthesia exposure in vulnerable patients
- Addresses the immediate life-threatening condition: Resolves the intestinal obstruction quickly
- Avoids complex biliary surgery: In patients with potentially poor physiological reserve
Evidence Supporting This Approach
Current evidence suggests that enterolithotomy alone is the safest approach for elderly patients with gallstone ileus. According to recent studies, "erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus has been shown to be a safe and effective treatment decision" 1.
While some studies advocate for a one-stage procedure (enterolithotomy plus fistula repair and cholecystectomy) in stable patients 3, this approach carries higher risks of complications in elderly patients. A retrospective study reported a 37.5% morbidity rate and 11% mortality rate with surgical management of gallstone ileus, with complications including wound dehiscence and infection 3.
Clinical Considerations and Caveats
- Preoperative stabilization is essential before any surgical intervention
- Careful assessment of comorbidities should guide surgical decision-making
- Risk of recurrence: While there is a small risk of recurrent gallstone ileus with enterolithotomy alone, this risk (5-10%) is outweighed by the increased surgical risk of the one-stage procedure in elderly patients
- Wound complications: Careful wound management is crucial as wound dehiscence has been reported as a postoperative complication 4
Special Situations
- In younger patients with good cardiorespiratory and metabolic reserve, a one-stage procedure may be considered 5
- If endoscopic retrieval is possible (particularly for colonic obstruction), this may be attempted before surgical intervention 6
- For patients with recurrent gallstone ileus, definitive management of the cholecystoduodenal fistula may be considered in a delayed fashion after recovery from the initial procedure 1