1. Management of Gallstone Ileus
Joint Hospital Surgical Grand Round
17th May, UCH
Cyrus Tse Tak Yin
TMH

2. 2 Patients Patient A I.O. OT on Jan 28, 2008 Patient B I.O.
Dx: Gallstone ileus
Patient B
I.O.
OT on Feb 3, 2008
Dx: Gallstone ileus
Enterolithotomy + Cholecystectomy + Repair of cholecystoduodenal fistula
Discharged on D7
Enterolithotomy
Discharged on D10

3. Management of GSI
Where are we standing?

4. Gallstone Ileus (GSI)
1st described by Bartolin in 1654
Misnomer

5. Gallstone Ileus 1-4% of mechanical intestinal obstruction
Elderly with multiple comorbidities
Female:Male 3.5:1

6. Gallstone Ileus
Size
<2cm
>5cm

7. Gallstone Ileus High peri-operative mortality rate
1890: Courvoisier 131 cases
Mortality: approaching 50%
Nowadays:
Mortality: 8-17%

8. Pathophysiology
Chronic recurrent inflammation + fistula formation

9. Pathophysiology Very rarely iatrogenic Endoscopic sphincterotomy
Oskam J et al. Acta Chir Belg 1993;92:43-5
Choledochoduodenostomy
Wakefield EG et al. Surgery 1939;5:674-7

10. Diagnosis Rigler’s Triad 40-50% I.O. Pneumobilia Aberrantly located GS
Rigler LG et al. JAMA 1941;117:1753

11. Diagnosis Pre-op Dx in <50% 2/3 -> diagnostic Balthazar 1978
2 adj fluid levels in RUQ. Medial -> duodenal bulb. Lateral -> GB.

12. Diagnosis USG -> 74% Ripolles T et al. Abdom Imag 2001;26:401-5
2/3 -> diagnostic
Balthazar 1978
2 adj fluid levels in RUQ. Medial -> duodenal bulb. Lateral -> GB.

13. Diagnosis CT -> localization, fistula
Lassandro F et al. AJR 2005;185:
2/3 -> diagnostic
Balthazar 1978
2 adj fluid levels in RUQ. Medial -> duodenal bulb. Lateral -> GB.

14. Management Spontaneous resolution reported but uncommon
Farooq A et al. Emerg Radiol :
Invariably requires surgery / treatment

15. Management
Resuscitation
Optimization
Selection

16. Treatment options 1 stage operation 2 stage operation Others
Enterolithotomy + cholecystectomy + closure of fistula
2 stage operation
Enterolithotomy
**+/- Subsequent cholecystectomy + closure of fistula
Others

17. Controversies 1 stage Higher mortality rates (16.9% vs 11.7%)
Reisner M et al. Am Surg 1994;60:441-6
Patient factor
Comorbidities
Disease factor
Local scarring and fibrosis, fistula
Surgeon factor
Expertise and experience

18. Controversies 2 stage Complications of cholelithiasis and fistula
Recurrent obstruction 5%
Ascending cholangitis / cholecystitis 15%
Inherent risks of 2nd operation
? risk of CA GB
Bossart et al: 15% incidence with fistula (vs 0.8%)
Clavien et al: Most fistulas well tolerated and close spontaneously without stone

19. Gallstone Ileus: A Review of 1001 Reported Cases
Gallstone Ileus: A Review of 1001 Reported Cases - Reisner RM and Cohen JR The American Surgeon ;60:

20. Reisner and Cohen
“…The procedure should be limited to dealing with the obstruction… Most patient will have no further problems. If symptoms related to the biliary tract return, elective cholecystectomy can be performed.”

21. Reisner and Cohen Multiple stones: 3-16%
Overlooked stones: recurrence in 2-10% of patients
“…This emphasizes the importance of a careful search for more stones throughout the entire GI tract.”
57% recurrence within 6 months

22. “… later biliary complications were prominent in patients treated only by enterolithotomy… a one-stage procedure is, when feasible, a valid option and may be the procedure of choice.”
Clavien PA et al. BJS 1990;77:
37 patients, 6.2years FU

23. Tan YM et al. Singapore Med J 2004;45(2):69-72
63% One stage (12/19)
“No significant differences in morbidity or outcomes between the 2 groups”
Tan YM et al. Singapore Med J 2004;45(2):69-72
57% recurrence within 6 months

24. Consensus?
57% recurrence within 6 months

25. Laparoscopic surgery Laparoscopic enterolithotomy
Allen JW et al. Surg Endosc 2003;17:352
Ferraina P et al. Surg Laparosc Endosc Percutan Tech 2003;13:83-87
Difficulty: detecting the location of GS esp with I.O.
Longer operating time

26. ESWL Difficult in localization
Successful case of GS in descending colon
Meyenberger C. et al. Gastrointest Endosc 1996;43:508-11

27. Endoscopic Intervention
Bouveret syndrome
Electrohydraulic lithotripsy
Bourke MJ et al. Gastrointest Endosc 1997;45:521-3
Mechanical lithotripsy
Moriai T et al. Am J Gastroenterol 1991;86:627-9

28. Our Experience

29. TMH Series
12 cases between Jan 2000 to May 2008

30. TMH Series - Operation

31. TMH Series Pre-op Dx: 4/12 (33.3%) 2 by AXR 1 by CT
1 by contrast study

32. Pneumobilia

33. Ectopic GS

34. GS + CD fistula

35. GS in Proximal Ileum

36. CD fistula

37. TMH Series - Site
No colon, no Bouveret

38. TMH Series
ASA 3+: 7/12 (58.3%)
Median time to OT: 2.3 days

39. TMH Series Immediate to Early Post-op Zero peri-operative mortality
8 - Uncomplicated
1 - Recurrence (D17)
2 - Chest infection
1 - AF
Zero peri-operative mortality

40. Cholecystitis

41. GS in terminal Ileum

42. TMH Series Enterolithotomy alone (n=9) 7 - Uncomplicated
1 - Recurrent obstruction (D17)
Cholecystectomy + Fistula repair done
1 - Acute cholecystitis, 2nd Stone
Conservative
1 - Recurrent cholangitis
Pending cholecystectomy

43. Conclusion

44. “In preparing for battle I have always found that plans are useless, but planning is indispensable.”
- Dwight Eisenhower,
Thank You