Management of Gallstone Ileus

Joint Hospital Surgical Grand Round 17th May, 2008 UCH

Cyrus Tse Tak YinTMH

2 Patients

Patient B I.O. OT on Feb 3, 2008

Dx: Gallstone ileus

Patient A I.O. OT on Jan 28, 2008

Dx: Gallstone ileus

Enterolithotomy + Cholecystectomy + Repair of cholecystoduodenal fistula

Discharged on D7

Enterolithotomy

Discharged on D10

Management of GSI

Where are we standing?

Gallstone Ileus (GSI)

1st described by Bartolin in 1654 Misnomer

Gallstone Ileus

1-4% of mechanical intestinal obstruction

Elderly with multiple comorbidities Female:Male 3.5:1

Gallstone Ileus

Size <2cm >5cm

Gallstone Ileus

High peri-operative mortality rate

1890: Courvoisier 131 cases Mortality: approaching 50%

Nowadays: Mortality: 8-17%

Pathophysiology

Chronic recurrent inflammation + fistula formation

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

Diagnosis

Rigler’s Triad I.O. Pneumobilia Aberrantly

located GS 40-50%

Rigler LG et al. JAMA 1941;117:1753

Diagnosis

Pre-op Dx in <50%

Diagnosis

USG -> 74% Ripolles T et al. Abdom Imag 2001;26:401-5

Diagnosis

CT -> localization, fistula Lassandro F et al. AJR 2005;185:1159-1165

Management

Spontaneous resolution reported but uncommon Farooq A et al. Emerg Radiol 2007 14:421-423

Invariably requires surgery / treatment

Management

Resuscitation Optimization Selection

Treatment options

1 stage operation Enterolithotomy + cholecystectomy +

closure of fistula 2 stage operation

Enterolithotomy **+/- Subsequent cholecystectomy +

closure of fistula

Others

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

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

Gallstone Ileus: A Review of 1001 Reported Cases

- Reisner RM and Cohen JR

The American Surgeon 1994;60:441-446

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.”

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.”

Clavien PA et al. BJS 1990;77:737-742

“… 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.”

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”

Consensus?

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

ESWL

Difficult in localization Successful case of GS

in descending colon

Meyenberger C. et al. Gastrointest Endosc 1996;43:508-11

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

Our Experience

TMH Series

12 cases between Jan 2000 to May 2008

TMH Series - Operation

9

3

012

345678

9

Type of Operation

Enterolithotomy Alone One stage

TMH Series

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

Pneumobilia I.O. GS Rigler's Triad50% 100% 50% 30%

Pneumobilia

Ectopic GS

GS + CD fistula

GS in Proximal Ileum

CD fistula

TMH Series - Site

No colon, no Bouveret

Distal Jejunum,2

DJ, 1

Proximal Ileum,2

Term. Ileum, 7

TMH Series

ASA 3+: 7/12 (58.3%)

Median time to OT: 2.3 days

TMH Series

Immediate to Early Post-op 8 - Uncomplicated 1 - Recurrence (D17) 2 - Chest infection 1 - AF

Zero peri-operative mortality

Cholecystitis

GS in terminal Ileum

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

Conclusion

Thank You

“In preparing for battle I have always found that plans are useless, but planning is indispensable.”

- Dwight Eisenhower, 1890-1969