Mortality Rate of Cholecystoenteric Fistula Takedown After Gallstone Ileus
The mortality rate for surgical takedown (closure) of a cholecystoenteric fistula after gallstone ileus ranges from 11-17% when performed as a one-stage procedure, compared to 5-12% for enterolithotomy alone in elderly patients with multiple comorbidities.
Overall Mortality Data
The mortality associated with fistula closure depends critically on the surgical approach chosen:
- One-stage procedure (enterolithotomy + fistula closure + cholecystectomy): mortality ranges from 11-17% 1, 2, 3
- Enterolithotomy alone (leaving fistula intact): mortality ranges from 5-12% 1, 3, 4
- Overall 30-day mortality across all surgical approaches for gallstone ileus: 5.5-15% 3, 4
Key Mortality Determinants
The high mortality in this population is driven by several factors:
- Advanced age: Mean age is typically 72-77 years, with gallstone ileus accounting for 25% of small bowel obstructions in patients over 65 1, 2, 3
- Comorbid conditions: Cardiorespiratory disease and diabetes are frequent and contribute substantially to mortality 2, 3
- Surgical complexity: One-stage procedures carry higher risk due to potential enteric or biliary leakage after fistula closure 2
Evidence-Based Surgical Approach Algorithm
For duodenal impaction sites:
- Perform one-stage operation (enterolithotomy + fistula repair + cholecystectomy) as the fistula is accessible in the same surgical field and outcomes are favorable 5
For small intestinal impaction sites:
- Perform enterolithotomy alone (two-stage approach), as natural fistula closure is expected and mortality is lower 5, 3
- Only 10% of patients require reoperation for continued biliary symptoms 3
- Recurrence rate of gallstone ileus is less than 5% 3
For colonic impaction sites:
- Perform one-stage operation, as natural closure is unlikely and patients face high risk of reflux cholangitis from fecal fluid 5
Critical Caveats
Reserve one-stage procedures only for:
- Patients in good general condition 2
- Low degree of cholecystitis present 2
- Stable hemodynamics and acceptable operative risk 1
Perform enterolithotomy alone for:
- Unstable patients 1
- Severe comorbidities precluding extended surgery 2, 3
- High-risk elderly patients (>80 years) 1
Morbidity Considerations
Beyond mortality, overall 30-day morbidity is 35-38%, with superficial surgical site infections and urinary tract infections being most common 2, 4. The cholecystectomy group experiences more minor complications, longer operative times, and longer postoperative hospitalization compared to enterolithotomy alone 4.
The critical clinical decision is balancing the 6-12% higher mortality risk of one-stage procedures against the small (<5%) risk of recurrent gallstone ileus and 10% risk of requiring future biliary surgery if the fistula is left intact 3.