Gallstone lleus Review of the Literature and Presentation of Thirty-Four New Cases Edwin A. Day, MD, New Orleans, Louisiana Charles Marks, MD, PhD, FRCP, FRCS, FACS, New Orleans, Louisiana
Gallstone ileus, a mechanical intestinal obstruction caused by impaction of one or more gallstones within the lumen of the bowel, was first described by Bartholin in 1654 [I]. Courvoisier [2] reported 131 cases of gallstone ileus in 1890, with a mortality of 44 per cent in the 125 operations performed for this condition. Martin [I], Rigler, Borman, and Noble [3], Foss and Summers [4], Deckoff [5], and Raiford [6] as well as other workers have reported cases. The purpose of this paper is to review thirtyfour consecutive cases of gallstone ileus at three Louisiana hospitals during the thirty-four year period from 1939 to 1973. Clinical Data The hospital records of nineteen patients with a diagnosis of gallstone ileus seen at three Louisiana hospitals representing the Louisiana State University Surgical Services from 1939 to the present were reviewed. An additional fifteen cases, previously described [7], are included in this study. During the period from 1954 to 1973, sixteen patients with a diagnosis of gallstone ileus were seen at Charity Hospital and at Touro Infirmary, New Orleans, Louisiana, and three patients were seen at Lafayette Charity Hospital. These cases are included in the present study to provide thirty-four cases seen over a period of thirtyfour years. The age range in this series was from thirty-seven to ninety-three years. Thirty-one patients were female and From the Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana. Reprint requests shoukl be addressed to Charles Marks, MD, Department of Surgery, Louisiana State University School of Medicine, 1542 Tulane Avenue, New Orleans, Louisiana 70112.
552
three were male; twenty-five were Caucasian and nine were Negro. A history of biliary disease was present in thirteen of the thirty-four patients. Almost one third (ten of thirtyfour patients) had experienced an acute episode of gallbladder disease within one year of admission for the definitive obstructive episode. Symptoms in the nineteen patients seen after 1954 with clearly documented clinical features were reviewed. All nineteen patients complained of abdominal pain; eighteen had vomiting. Constipation was the next most frequent complaint, and anorexia and abdominal distention were commonly present. Serious concomitant disease was present in fifteen of these patients; twelve had associated cardiovascular disease and three had diabetes. Abdominal tenderness was the most frequent physical finding, exhibited by fifteen of the nineteen patients. Abdominal distention was present in eleven patients, and nearly half the patients (nine of nineteen) had exaggerated ausculatory bowel sounds on admission. Two patients in the entire series presented with jaundice and two had melanotic stools. Laboratory studies revealed that seventeen of this group of patients were dehydrated and had electrolyte imbalance on admission, all but one being azotemic as a result of dehydration. Five of the nineteen patients had abnormal results of liver function studies. In the entire series of thirty-four patients, the interval from onset of symptoms to hospital admission varied from twelve hours to one month. Thirty-two patients underwent surgical exploration. In these thirty-two, the timing of the surgical procedure varied from immediate emergency operation to delay of twenty-seven days in one patient. Thirteen of the thirty-four patients in the total series (38 per cent) had radiologic features that indicated gallstone ileus, yet only once was a diagnosis of gallstone
The Amerkan Journal of Surgery
@lIstone lleus
ileus made on admission. Intestinal obstruction of unknown cause was suspected in twenty patients; adhesions were considered to be the cause of obstruction in three, and a diagnosis of cholecystitis was made in three other patients. Information concerning the size of the obstructing gallstone is available for sixteen patients in the entire series. The stones measured 1.4 to 5.6 cm in diameter; in only three cases was the stone smaller than 2.5 cm. It was possible to ascertain the site of obstruction in thirty-two patients. In twenty-one patients the ileum was identified as the site of obstruction. In one patient the stone was impacted at the ileocecal valve. In three patients more than one stone was present; in one of these patients the stone was intragastric, and in another a stone was impacted in the duodenum. No stones were found in the colon or rectum. Thirty-two patients underwent operative procedures. Of the two patients not undergoing operation, one was a seventy-five year old woman who presented with a one week history of abdominal pain, abdominal distention, and jaundice. She was thought to have obstruction of the common bile duct with accompanying ileus. She was treated nonoperatively and her course was that of intermittent intestinal obstruction until one month after admission, at which time the obstructing stone was passed spontaneously and she subsequently recovered. The other patient treated nonoperatively was a seventy-five year old woman who presented with a nineteen day history of abdominal pain and vomiting. On admission she was in shock and severely dehydrated and had marked electrolyte imbalance. On her first day in the hospital a cold developed and mottling in the right lower extremity was noted; she was thought to have thrombosis of the right iliac or femoral artery. Her course deteriorated rapidly and she died after three days. Autopsy revealed gallstone ileus and thrombosis of the abdominal aorta. Twenty-five patients were treated by enterotomy and extraction of the obstructing stone. Three patients had cholecystectomy and fistula repair in one stage as part of the initial procedure. In addition, one of these three patients underwent exploration of the common bile duct. Removal of the obstructing stone was accompanied by resection of small bowel in three other patients. One patient with a stone impacted in the duodenum was treated by duodenotomy, milking the stone proximally and extracting it through a gastrotomy; cholecystectomy was also performed. Seven of the thirty-four patients died; among the thirty-two patients who underwent surgery there were six deaths. There were three deaths in the group of patients undergoing enterotomy alone (12 per cent mortality). One of these patients had been found at operation to have carcinoma of the gallbladder with widespread carcinomatosis and died fourteen days after enterotomy. Two of the three patients undergoing small bowel resection died (66 per cent mortality). All three patients who underwent one stage cholecystectomy, fistula repair, and enterotomy survived.
Volume129,May1975
Information regarding postoperative complications is available for fourteen of the thirty-two patients. Wound infection developed in three patients postoperatively, and two of these patients had undergone one stage cholecystectomy, fistula repair, and enterotomy. Two patients had gastrointestinal bleeding postoperatively. One patient who had undergone resection of small bowel had gastrointestinal bleeding seven days postoperatively and was treated by transfusion of 2 units of whole blood. The patient died the following day and autopsy revealed failure of the ileal anastomosis. The second patient had gastrointestinal bleeding in the postoperative period presumably from diverticulosis and responded to transfusion of 2 units of whole blood. Six years after discharge, this patient was readmitted with idiopathic thrombocytopenic purpura and a bleeding gastric ulcer for which she underwent vagotomy, pyloroplasty, and suture of the bleeding points. The patient subsequently died and autopsy revealed a patent cholecystoduodenal fistula. Aspiration pneumonia developed in another patient and required prolonged ventilatory support in the postoperative period. From the follow-up data available, only three patients in the series of thirty-two patients who underwent operation have had recurrent symptoms of biliary disease. One was a forty-five year old woman who underwent enterotomy and had an uneventful postoperative course; less than one year after discharge, flatulence and fatty food intolerance developed. She did not undergo reoperation, however, and was asymptomatic when last followed up eight years postoperatively. Another patient, a fifty-six year old Negro woman, continued to complain of fatty food intolerance, vague pains, and soreness in the right upper quadrant two and a half years after enterotomy. She was the only patient who had reoperation for recurrent symptoms after the initial procedure; she underwent cholecystectomy and fistula repair. A third patient returned with painless jaundice one year after enterolithotomy and resection of small bowel. Physical examination revealed a palpable fullness in the right upper quadrant, and liver function studies indicated biliary obstruction. Exploration revealed carcinoma of the gallbladder. The abdomen was closed with no definitive procedure being performed, and the patient was still alive when seen three months postoperatively. Comments Among
large series the incidence
obstruction
of the small intestine
is between
1 and
3 per
cent.
of mechanical
due to gallstones The
incidence
in-
creases to 23 to 25 per cent in patients over sixtyfive years of age. Gallstone ileus is a complication in 0.3 to 0.5 per cent Martin per states pect
of all cases of cholelithiasis.
[1] computed
30,000 that to
one case
operations
of all
the average
general
find
one
case
of gallstone types. surgeon
of intestinal
Raiford might
ileus [6] ex-
obstruction
553
Day and Marks
caused by gallstones in 8,500 cases requiring major operations, in 300 cases of cholelithiasis, and in 35 cases of intestinal obstruction of all types that he might encounter. Becker reviewed 1,007 cases of acute mechanical obstruction occurring at Charity Hospital in the ten year period from 1940 through 1949 [7]. Only one of these cases was due to gallstones, providing an incidence of 0.1 per cent at our institution. The number of reported cases of gallstone ileus in the literature has been estimated between 800 and 1,000. The typical patient with gallstone ileus is in the sixth or seventh decade of life, with the average age reported between sixty-six and seventy-three years. In our serie’s the average age was 67.3 years. Reports have suggested a preponderance of gallstone ileus in the female that varies from 3:l to 16:1, with most large series reporting it to be in the range of 7:l or 81. In our series, the female to male ratio was 1O:l. Deckoff [5] suggests that the preponderance in women is higher than anticipated, since cholelithiasis reportedly occurs three to six times more commonly in women than in men. The twelve patients with gallstone ileus in Deckoff’s series were all female. Bretow and Crampton [8] report an apparent preponderance among Caucasians, and this racial preponderance is reflected in our series, with a Caucasian to Negro ratio of 3:~ The incidence of serious disease concomitant with gallstone ileus is high, contributing to its high mortality and morbidity. In our series diabetes mellitus was present in 50 per cent of the cases, major cardiovascular disease in 58 per cent, and major obesity in 58 per cent. Half of the patients in the series of Moore and Baker [9] had heart disease, and 40 per cent had diabetes. Eighty per cent of patients in the series of Piedad and Wels [IO] had previously diagnosed associated disease, most commonly arteriosclerotic cardiovascular disease, followed by pulmonary disease and diabetes. In our series, in cases in which such information is recorded, serious associated disease was present in 79 per cent of patients with gallstone ileus, 63 per cent presenting with cardiovascular disease and 15.8 per cent with diabetes mellitus. The obstructing stone in gallstone ileus usually originates in the gallbladder, although two cases of gallstone ileus have been reported in which the gallbladder was absent, having been removed previously. Obstruction results when the stone enters the gastrointestinal tract, usually through a cholecystoenteric fistula. In most cases the fistula is located between the gallbladder and the duodenum. In the series reported by Wakefield, Vickers, and
554
Walters [If] from the Mayo Clinic in which 176 fistulas were studied, the site of perforation involved the duodenum in one hundred and one, the colon in thirty-three, the stomach in seven, and multiple sites were involved in eleven. In one series of forty-two cases at autopsy, cholecystoduodenal fistulas were present in forty-one [4]. In all eleven cases in our series in which the site of the biliary enteric fistula was recorded, it was cholecystoduodenal. Once within the intestinal tract, a gallstone may be vomited, may pass spontaneously through the rectum, or may impact to cause obstruction. According to Gutmann [12], less than half the stones entering the alimentary tract will cause obstruction, because many stones are excreted uneventfully in the stools. Most reports indicate that stones smaller than 2.5 cm usually pass spontaneously, although smaller stones have produced fatal ileus and stones as large as 5 cm have passed spontaneously. The largest stone causing intestinal obstruction was reported by Gray-Turner [13]; he successfully removed from the transverse colon a gallstone measuring 17.7 cm in its largest diameter. Data regarding dimensions of the obstructing stone in our series indicate an average size of 3.5 cm. The site of obstruction is usually the terminal ileum, as it is the narrowest portion of the small bowel. Foss and Summers [4] noted that in 70 per cent of a collected series, obstruction occurred in the terminal ileum. In 69 per cent of the patients in our series obstruction occurred in the ileum, and when specified in these patients, the distal ileum was the site of obstruction in 57 per cent. In one of these patients, a gallstone was impacted at the ileocecal valve. Only one of our patients presented with obstruction due to an intraduodenal gallstone (3.1 per cent of thirty-two cases). Printen and Safaie-Shirazi [14] have recently reported six similar cases and state that duodenal obstruction usually occurs in 1 to 3 per cent of patients with gallstone ileus. Obturation of the small intestine by a gallstone. leads to marked losses of fluid and electrolytes in the majority of patients. With high obstruction, bilious vomiting is characteristic; with ileal obstruction, feculent vomiting and abdominal distention are more prominent. When perforation of the bowel occurs, fever, toxicity, and signs of peritonitis may be noted. The clinical picture of gallstone ileus is similar to that of any mechanical bowel obstruction. The symptoms are intermittent as the stone lodges at various levels, causing in-
The Amorksm Journal of Surgwy
Gallstone lleus
complete small bowel obstruction characterized as “tumbling obstruction.” Because of the intermittent nature of symptoms, diagnosis is often delayed. Approximately half the patients with gallstone ileus have a history of gallbladder disease; 47 per cent of the patients in our series had a history of gallbladder disease. A recent acute biliary episode frequently precedes the onset of gallstone ileus; 32 per cent of the patients described by Foss and Summers [4] and 25 per cent in Deckoff’s series [5] presented this feature. An acute episode of gallbladder disease had occurred in 26 per cent of our patients within one year of admission for gallstone ileus. A history of jaundice has been reported in 8 to 15 per cent of patients with gallstone ileus. Only one patient in our series of thirty-four (3 per cent) had had a previous episode of jaundice. In several large series of gallstone ileus, the most common complaints included cramping abdominal pain, nausea and vomiting, abdominal distention, and obstipation. In our series, when data regarding symptoms are available, 100 per cent of the patients complained of abdominal pain, 95 per cent had vomiting, and 47 per cent had constipation. Anorexia and abdominal distention each was included among the presenting complaints in 26 per cent of the patients. The interval between the onset of symptoms and time of admission to the hospital averages four to five days in most series. In our series an average of seven days had elapsed from onset of symptoms to hospitalization. Symptoms of progressive obstruction in an elderly obese woman who has undergone no previous abdominal surgery strongly suggest gallstone ileus, especially if she has a history of gallbladder disease. Yet a correct preoperative diagnosis is not made frequently. In several recent series, a correct preoperative diagnosis was made 37 to 57 per cent of the time. Preoperative diagnosis was correct in only two of nineteen (10.5 per cent) of our patients in whom this information is available. The physical examination in patients with gallstone ileus is usually difficult because of abdominal distention, muscle guarding, dehydration, obesity, and the presence in many instances of concurrent disease. In several series, the most common signs are abdominal tenderness, abdominal distention, and hyperperistalsis. Jaundice is uncommon. Dehydration is usually present. In our series when data regarding physical signs are available, 79 per cent of patients had abdominal tenderness on examination, 57 per cent bad abdominal distention,
Volume 129, May 197s
Figure 1. Radiograph of abdomen demonstrates pneumobilia.
47 per cent had obstructive bowel sounds, and 6 per cent were jaundiced. Laboratory studies are usually nonspecific but reflect dehydration and electrolyte imbalance. All of the patients in our series with available laboratory data had electrolyte imbalance on admission, 84 per cent had azotemia, and 32 per cent had abnormal results of liver function studies. The abdominal scout film is of major importance in establishing a diagnosis. In 1941, Rigler, Borman, and Noble [3] described four roentgenographic signs in gallstone ileus: (1) air in the biliary tree, which was seen preoperatively in ten of the thirty-four patients (29 per cent) in our series evidence of par(Figure 1); (2) roentgenographic tial or complete intestinal obstruction, which was seen preoperatively in eighteen of thirty-four patients (53 per cent) (Figure 1); (3) direct or indirect visualization of the obstructing stone by means of contrast medium in the intestine, which occurred in twelve of thirty-four patients (35 per cent) (Figure 2); (4) change in position of a previously observed stone, which was seen in two of thirty-four patients (6 per cent). In addition to the scout film, specific studies have been used. Barium contrast x-ray films proved useful in four of the thirty-four patients
555
Day and Marks
(Figure 3), and in one of these the diagnosis was made preoperatively on the basis of hypotonic duodenography that revealed the obstructing gall-
Figure 2. Radiopaque gallstone vtsualked in right lower quadrant.
Figure 3. Reflux of barium through cholecystoduodenal fistuia visualized radiographically.
556
stone. The interval between admission and operation varied between two and four days in several recent series. In our series, an average of 3.2 days elapsed before operation in the thirty-two patients who underwent operation. Most authors recommend enterotomy alone as the initial treatment in the surgical approach to gallstone ileus. Fraser [15], Kirkland and Croce [16], and Malt [17] recommend enterolithotomy and cholecystostomy with stone removal when calculi are palpated in the gallbladder. Many authorities consider additional biliary surgery to be unwise at the time of initial laparotomy. Whether operation in the biliary tree should be undertaken at a later date is a controversial question. Many authors advocate cholecystectomy and repair of the fistula at a second elective procedure as soon after initial operation as possible, citing a 5 per cent risk of recurrent gallstone ileus. Berliner and Burson [IS] stress that, in addition to the risks of recurrent cholecystitis, the incidence of carcinoma of the gallbladder may increase in patients with gallstone ileus. Severe upper gastrointestinal bleeding has also been reported a!+ a late complication of gallstone ileus. Rogers and Carter [19] as well as others state that surgical treatment of cholecystoenteric fistulas should be performed only if warranted by further symptoms of gallbladder disease. In support of this, Raiford [6] and Serino [20] maintain that when the cystic duct is patent the fistula will probably close spontaneously. It has been stressed that even when the fistula remains patent the danger of complications would be small. More recent authors have advocated a more aggressive approach to gallstone ileus, which includes cholecystectomy and fistula repair in conjunction with enterotomy for obstruction. Many undesirable sequelae after enterolithotomy alone could be avoided by a one stage operation. In two separate series, 30 per cent of those treated by enterotomy had further complications related to the gallbladder or fistula. In the series of Cooperman, Dickson, and ReMine [21], two of six patients treated by enterotomy alone had continuing symptoms; a third had recurrence of gallstone ileus one year after the initial episode. The incidence of carcinoma of the gallbladder is allegedly higher in the presence of biliary enteric fistula. Berliner and Burson [18] reviewed fifty-
The Amerkan Journal ol Surgery
Gallstone
seven cases of gallstone ileus with fistula demonstrated at either operation or autopsy. Within this series were eight cases of primary carcinoma of the gallbladder, an incidence of.15 per cent. This is in marked contrast to the 1.12 per cent incidence of carcinoma occurring in all operations on the biliary tract. In our series of thirty-four patients with gallstone ileus, there were two patients (6 per cent) in whom carcinoma of the gallbladder developed. One patient exhibited widespread carcinomatosis (of the gallbladder) at the time of operation for gallstone ileus. In the other, exploration one year after the initial operation for gallstone ileus revealed carcinoma of the gallbladder. At the time of initial operation this latter patient had undergone enterolithotomy and small bowel resection without fistula repair. Berliner and Burson [18] stress that the longer the patient with a fistula survives, the greater the chance of carcinoma occurring. Another undesirable sequela of a patent fistula is cholangitis; its incidence in cholecystoduodenal fistula has been reported as high as 11 per cent. Complications reportedly resulting from cholecystocolonic fistulas, which comprise 14 per cent of all biliary fistulas, have included weight loss (related to a malabsorption syndrome), cholangitis, and empyema of the gallbladder with fatal perforation. Pybus [22] in 1922 resected a cholecystoduodenal fistula and performed cholecystostomy during ileotomy for obstructing gallstones. Holz [23] in 1929 inadvertently entered a cholecystoduodenal fistula while attempting to extract an impacted duodenal stone; since closure of the fistula was necessary, he elected to remove the gallbladder. Welch, Huizanga, and Roberts [24] reported a one stage cholecystectomy, closure of the cholecystoenteric fistula, and relief of the obstruction by enterolithotomy in 1957. Primary repair has been advocated more recently by Warshaw and Bartlett [25], Berliner and Burson [18], Fox [26], and Cooperman, Dickson, and ReMine [21]. The latter reported the largest current series of one stage treatment, with only one death. At the time of this report only twenty-three cases managed in this way have been reported in the English literature. The three patients treated by one stage repair in our series increases this total to twenty-six. Recent data indicate that, with proper patient selection and preoperative preparation, one stage cholecystectomy, fistula repair, and enterolithotomy for gallstone ileus do not result in a significantly higher mortality than does enterotomy alone, even considering the progressive decline in
Volume 129, May 1975
lleus
mortality after enterotomy alone during the past several decades, Prior to 1925, more than.60 per cent of patients with gallstone ileus died. Several recent series show mortality rates of less than 15 per cent and in some series there have been no fatalities. The overall mortality in our series was 21 per cent, operative mortality was 19 per cent, and enterotomy alone had a mortality of 14 per cent. In the largest reported series of elective one stage resections, the operative mortality was 13 per cent, with one death in eight patients; the authors reported the mortality after enterotomy alone also was 13 per cent [21]. The three cases of one stage repair in our series are added to the twenty-three previously reported to substantiate the validity of one stage repair in dealing with the entire disease process during one operative procedure, thus eliminating the known high morbidity after enterotomy alone. Whichever operative procedure is carried out, wound infection has been rather prominent among postoperative complications and reported to be as high as 75 per cent in two separate series. Likelihood of postoperative wound infection is high, considering the obesity of these patients combined with the unavoidable contamination from the content of the obstructed bowel. Summary An analysis of thirty-four patients with gallstone ileus is integrated with a review of the literature on the subject. Surgical treatment was carried out in thirty-two patients, with an overall operative mortality of 19 per cent. Three patients were treated by one stage enterolithotomy, fistula repair, and cholecystectomy without operative mortality, emphasizing the merit of one stage treatment in selected, well prepared patients. A 6 per cent incidence of carcinoma of the gallbladder was noted in this series of patients.
References 1. Martin F: Intestinal obstruction due to gallstones. Ann Surg 55: 725, 1912. 2. Courvoisier LT: Zasurstisch-statistische Beitrage zur Pathologie und Chirurgie der Gallenwege. Leipzig, FCW Vogel, 1890. 3. Rigler LG. Barman CN, Noble JF: Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 117: 1753,194l. 4. Foss HL, Summers JD: Intestinal obstruction from gallstones. Ann Surg 115: 721, 1942. 5. Deckoff SL: Gallstone ileus: a report of 12 cases. Ann Surg 142: 52, 1955.
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6. Raiford TS: Intestinal obstruction caused by gallstones. Am J Surg 104: 383, 1962. 7. Karlin S, Miller WC: Gallstone obstruction of the small bowel. J La State Med Sot 106: 391, 1954. 8. Bretow GW, Crampton RS: Gallstone ileus: a report of 23 cases. Arch Surg 86: 504. 1963. 9. Moore TC, Baker WH: Operative and radiologic relief of gallstone intestinal obstruction. Surg Gynecol Cbstet 116: 189, 1963. 10. Piedad OH, Wels PB: Spontaneous Internal biliary fist&, obstructive and non-obstructive types: twenty year review of 55 cases. Ann Surg 175: 75, 1972. 11. Wakefield EG, Vickers PM, Walters W: Intestinal obstructlon caused by gallstones. Surgery 5: 670, 1939. 12. Gutmann JH: lleus due to migrating gallstones. Am J Surg 30: 548, 1935. 13. Turner GG: A giant gallstone impacted in the colon and causing acute obstruction. Br J Surg 20: 26, 1932. 14. Printen KJ, SafaiaShirazi S: Duodenal obstruction caused by gallstones: report of six cases. Am Surg 39: 688, 1973. 15. Fraser WJ: Intestinal obstruction by gallstone. Br J Surg 42: 210, 1954. 16. Kirkland KC, Croce EJ: Gallstone intestinal obstruction. JAMA 176: 494, 1961.
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17. Malt RA: Experience with recurrent gallstone ileus applied to management of the first attack. Am J Surg 108: 92, 1964. 18. Berliner SD, Burson LC: One-stage repair for cholecystduodenal fistula and gallstone ileus. Arch Surg 90: 313, 1965. 19. Rogers FA, Carter R: Recurrent gallstone ileus. Am J Surg 96: 379, 1958. 20. Serino GS: Gallstone ileus in a 95-year-old woman: a case report with six-year follow-up studies. Geriatrics 14: 257, 1959. 21. Cooperman AM, Dickson ER, ReMine WH: Changing concepts in the surgical treatment of gal&tone ileus: a review of 15 cases with emphasis on diagnosis and treatment. Ann Surg 167: 377, 1968. 22. Pybus FC: A note on two cases of gallstone ileus. Lancet 2: 812, 1922. 23. Holz E: Zur Frage des Gallenstein Ileus. Arch K/in Chir 155: 16, 1929. 24. Welch JS. Huizanga KA, Roberts SE: Recurrent intestinal obstruction due to gallstones. Mayo C/in Proc 32: 628, 1957. 25. Warshaw AL, Bartlett MK: Choice of operation for gallstone intestinal obstruction. Ann Surg 164: 1051. 1966. 26. Fox PF: Planning the operation for cholecystoenteric fistula with gallstone ileus. Surg C/in North Am 50: 93, 1970.
The American Journal of Surgery
Gallstone ileus, a mechanical intestinal obstruction caused by impaction of one or more gallstones within the lumen of the bowel, was first described by Bartholin in 1654 [I]. Courvoisier [2] reported 131 cases of gallstone ileus in 1890, with a mortality of 44 per cent in the 125 operations performed for this condition. Martin [I], Rigler, Borman, and Noble [3], Foss and Summers [4], Deckoff [5], and Raiford [6] as well as other workers have reported cases. The purpose of this paper is to review thirtyfour consecutive cases of gallstone ileus at three Louisiana hospitals during the thirty-four year period from 1939 to 1973. Clinical Data The hospital records of nineteen patients with a diagnosis of gallstone ileus seen at three Louisiana hospitals representing the Louisiana State University Surgical Services from 1939 to the present were reviewed. An additional fifteen cases, previously described [7], are included in this study. During the period from 1954 to 1973, sixteen patients with a diagnosis of gallstone ileus were seen at Charity Hospital and at Touro Infirmary, New Orleans, Louisiana, and three patients were seen at Lafayette Charity Hospital. These cases are included in the present study to provide thirty-four cases seen over a period of thirtyfour years. The age range in this series was from thirty-seven to ninety-three years. Thirty-one patients were female and From the Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana. Reprint requests shoukl be addressed to Charles Marks, MD, Department of Surgery, Louisiana State University School of Medicine, 1542 Tulane Avenue, New Orleans, Louisiana 70112.
552
three were male; twenty-five were Caucasian and nine were Negro. A history of biliary disease was present in thirteen of the thirty-four patients. Almost one third (ten of thirtyfour patients) had experienced an acute episode of gallbladder disease within one year of admission for the definitive obstructive episode. Symptoms in the nineteen patients seen after 1954 with clearly documented clinical features were reviewed. All nineteen patients complained of abdominal pain; eighteen had vomiting. Constipation was the next most frequent complaint, and anorexia and abdominal distention were commonly present. Serious concomitant disease was present in fifteen of these patients; twelve had associated cardiovascular disease and three had diabetes. Abdominal tenderness was the most frequent physical finding, exhibited by fifteen of the nineteen patients. Abdominal distention was present in eleven patients, and nearly half the patients (nine of nineteen) had exaggerated ausculatory bowel sounds on admission. Two patients in the entire series presented with jaundice and two had melanotic stools. Laboratory studies revealed that seventeen of this group of patients were dehydrated and had electrolyte imbalance on admission, all but one being azotemic as a result of dehydration. Five of the nineteen patients had abnormal results of liver function studies. In the entire series of thirty-four patients, the interval from onset of symptoms to hospital admission varied from twelve hours to one month. Thirty-two patients underwent surgical exploration. In these thirty-two, the timing of the surgical procedure varied from immediate emergency operation to delay of twenty-seven days in one patient. Thirteen of the thirty-four patients in the total series (38 per cent) had radiologic features that indicated gallstone ileus, yet only once was a diagnosis of gallstone
The Amerkan Journal of Surgery
@lIstone lleus
ileus made on admission. Intestinal obstruction of unknown cause was suspected in twenty patients; adhesions were considered to be the cause of obstruction in three, and a diagnosis of cholecystitis was made in three other patients. Information concerning the size of the obstructing gallstone is available for sixteen patients in the entire series. The stones measured 1.4 to 5.6 cm in diameter; in only three cases was the stone smaller than 2.5 cm. It was possible to ascertain the site of obstruction in thirty-two patients. In twenty-one patients the ileum was identified as the site of obstruction. In one patient the stone was impacted at the ileocecal valve. In three patients more than one stone was present; in one of these patients the stone was intragastric, and in another a stone was impacted in the duodenum. No stones were found in the colon or rectum. Thirty-two patients underwent operative procedures. Of the two patients not undergoing operation, one was a seventy-five year old woman who presented with a one week history of abdominal pain, abdominal distention, and jaundice. She was thought to have obstruction of the common bile duct with accompanying ileus. She was treated nonoperatively and her course was that of intermittent intestinal obstruction until one month after admission, at which time the obstructing stone was passed spontaneously and she subsequently recovered. The other patient treated nonoperatively was a seventy-five year old woman who presented with a nineteen day history of abdominal pain and vomiting. On admission she was in shock and severely dehydrated and had marked electrolyte imbalance. On her first day in the hospital a cold developed and mottling in the right lower extremity was noted; she was thought to have thrombosis of the right iliac or femoral artery. Her course deteriorated rapidly and she died after three days. Autopsy revealed gallstone ileus and thrombosis of the abdominal aorta. Twenty-five patients were treated by enterotomy and extraction of the obstructing stone. Three patients had cholecystectomy and fistula repair in one stage as part of the initial procedure. In addition, one of these three patients underwent exploration of the common bile duct. Removal of the obstructing stone was accompanied by resection of small bowel in three other patients. One patient with a stone impacted in the duodenum was treated by duodenotomy, milking the stone proximally and extracting it through a gastrotomy; cholecystectomy was also performed. Seven of the thirty-four patients died; among the thirty-two patients who underwent surgery there were six deaths. There were three deaths in the group of patients undergoing enterotomy alone (12 per cent mortality). One of these patients had been found at operation to have carcinoma of the gallbladder with widespread carcinomatosis and died fourteen days after enterotomy. Two of the three patients undergoing small bowel resection died (66 per cent mortality). All three patients who underwent one stage cholecystectomy, fistula repair, and enterotomy survived.
Volume129,May1975
Information regarding postoperative complications is available for fourteen of the thirty-two patients. Wound infection developed in three patients postoperatively, and two of these patients had undergone one stage cholecystectomy, fistula repair, and enterotomy. Two patients had gastrointestinal bleeding postoperatively. One patient who had undergone resection of small bowel had gastrointestinal bleeding seven days postoperatively and was treated by transfusion of 2 units of whole blood. The patient died the following day and autopsy revealed failure of the ileal anastomosis. The second patient had gastrointestinal bleeding in the postoperative period presumably from diverticulosis and responded to transfusion of 2 units of whole blood. Six years after discharge, this patient was readmitted with idiopathic thrombocytopenic purpura and a bleeding gastric ulcer for which she underwent vagotomy, pyloroplasty, and suture of the bleeding points. The patient subsequently died and autopsy revealed a patent cholecystoduodenal fistula. Aspiration pneumonia developed in another patient and required prolonged ventilatory support in the postoperative period. From the follow-up data available, only three patients in the series of thirty-two patients who underwent operation have had recurrent symptoms of biliary disease. One was a forty-five year old woman who underwent enterotomy and had an uneventful postoperative course; less than one year after discharge, flatulence and fatty food intolerance developed. She did not undergo reoperation, however, and was asymptomatic when last followed up eight years postoperatively. Another patient, a fifty-six year old Negro woman, continued to complain of fatty food intolerance, vague pains, and soreness in the right upper quadrant two and a half years after enterotomy. She was the only patient who had reoperation for recurrent symptoms after the initial procedure; she underwent cholecystectomy and fistula repair. A third patient returned with painless jaundice one year after enterolithotomy and resection of small bowel. Physical examination revealed a palpable fullness in the right upper quadrant, and liver function studies indicated biliary obstruction. Exploration revealed carcinoma of the gallbladder. The abdomen was closed with no definitive procedure being performed, and the patient was still alive when seen three months postoperatively. Comments Among
large series the incidence
obstruction
of the small intestine
is between
1 and
3 per
cent.
of mechanical
due to gallstones The
incidence
in-
creases to 23 to 25 per cent in patients over sixtyfive years of age. Gallstone ileus is a complication in 0.3 to 0.5 per cent Martin per states pect
of all cases of cholelithiasis.
[1] computed
30,000 that to
one case
operations
of all
the average
general
find
one
case
of gallstone types. surgeon
of intestinal
Raiford might
ileus [6] ex-
obstruction
553
Day and Marks
caused by gallstones in 8,500 cases requiring major operations, in 300 cases of cholelithiasis, and in 35 cases of intestinal obstruction of all types that he might encounter. Becker reviewed 1,007 cases of acute mechanical obstruction occurring at Charity Hospital in the ten year period from 1940 through 1949 [7]. Only one of these cases was due to gallstones, providing an incidence of 0.1 per cent at our institution. The number of reported cases of gallstone ileus in the literature has been estimated between 800 and 1,000. The typical patient with gallstone ileus is in the sixth or seventh decade of life, with the average age reported between sixty-six and seventy-three years. In our serie’s the average age was 67.3 years. Reports have suggested a preponderance of gallstone ileus in the female that varies from 3:l to 16:1, with most large series reporting it to be in the range of 7:l or 81. In our series, the female to male ratio was 1O:l. Deckoff [5] suggests that the preponderance in women is higher than anticipated, since cholelithiasis reportedly occurs three to six times more commonly in women than in men. The twelve patients with gallstone ileus in Deckoff’s series were all female. Bretow and Crampton [8] report an apparent preponderance among Caucasians, and this racial preponderance is reflected in our series, with a Caucasian to Negro ratio of 3:~ The incidence of serious disease concomitant with gallstone ileus is high, contributing to its high mortality and morbidity. In our series diabetes mellitus was present in 50 per cent of the cases, major cardiovascular disease in 58 per cent, and major obesity in 58 per cent. Half of the patients in the series of Moore and Baker [9] had heart disease, and 40 per cent had diabetes. Eighty per cent of patients in the series of Piedad and Wels [IO] had previously diagnosed associated disease, most commonly arteriosclerotic cardiovascular disease, followed by pulmonary disease and diabetes. In our series, in cases in which such information is recorded, serious associated disease was present in 79 per cent of patients with gallstone ileus, 63 per cent presenting with cardiovascular disease and 15.8 per cent with diabetes mellitus. The obstructing stone in gallstone ileus usually originates in the gallbladder, although two cases of gallstone ileus have been reported in which the gallbladder was absent, having been removed previously. Obstruction results when the stone enters the gastrointestinal tract, usually through a cholecystoenteric fistula. In most cases the fistula is located between the gallbladder and the duodenum. In the series reported by Wakefield, Vickers, and
554
Walters [If] from the Mayo Clinic in which 176 fistulas were studied, the site of perforation involved the duodenum in one hundred and one, the colon in thirty-three, the stomach in seven, and multiple sites were involved in eleven. In one series of forty-two cases at autopsy, cholecystoduodenal fistulas were present in forty-one [4]. In all eleven cases in our series in which the site of the biliary enteric fistula was recorded, it was cholecystoduodenal. Once within the intestinal tract, a gallstone may be vomited, may pass spontaneously through the rectum, or may impact to cause obstruction. According to Gutmann [12], less than half the stones entering the alimentary tract will cause obstruction, because many stones are excreted uneventfully in the stools. Most reports indicate that stones smaller than 2.5 cm usually pass spontaneously, although smaller stones have produced fatal ileus and stones as large as 5 cm have passed spontaneously. The largest stone causing intestinal obstruction was reported by Gray-Turner [13]; he successfully removed from the transverse colon a gallstone measuring 17.7 cm in its largest diameter. Data regarding dimensions of the obstructing stone in our series indicate an average size of 3.5 cm. The site of obstruction is usually the terminal ileum, as it is the narrowest portion of the small bowel. Foss and Summers [4] noted that in 70 per cent of a collected series, obstruction occurred in the terminal ileum. In 69 per cent of the patients in our series obstruction occurred in the ileum, and when specified in these patients, the distal ileum was the site of obstruction in 57 per cent. In one of these patients, a gallstone was impacted at the ileocecal valve. Only one of our patients presented with obstruction due to an intraduodenal gallstone (3.1 per cent of thirty-two cases). Printen and Safaie-Shirazi [14] have recently reported six similar cases and state that duodenal obstruction usually occurs in 1 to 3 per cent of patients with gallstone ileus. Obturation of the small intestine by a gallstone. leads to marked losses of fluid and electrolytes in the majority of patients. With high obstruction, bilious vomiting is characteristic; with ileal obstruction, feculent vomiting and abdominal distention are more prominent. When perforation of the bowel occurs, fever, toxicity, and signs of peritonitis may be noted. The clinical picture of gallstone ileus is similar to that of any mechanical bowel obstruction. The symptoms are intermittent as the stone lodges at various levels, causing in-
The Amorksm Journal of Surgwy
Gallstone lleus
complete small bowel obstruction characterized as “tumbling obstruction.” Because of the intermittent nature of symptoms, diagnosis is often delayed. Approximately half the patients with gallstone ileus have a history of gallbladder disease; 47 per cent of the patients in our series had a history of gallbladder disease. A recent acute biliary episode frequently precedes the onset of gallstone ileus; 32 per cent of the patients described by Foss and Summers [4] and 25 per cent in Deckoff’s series [5] presented this feature. An acute episode of gallbladder disease had occurred in 26 per cent of our patients within one year of admission for gallstone ileus. A history of jaundice has been reported in 8 to 15 per cent of patients with gallstone ileus. Only one patient in our series of thirty-four (3 per cent) had had a previous episode of jaundice. In several large series of gallstone ileus, the most common complaints included cramping abdominal pain, nausea and vomiting, abdominal distention, and obstipation. In our series, when data regarding symptoms are available, 100 per cent of the patients complained of abdominal pain, 95 per cent had vomiting, and 47 per cent had constipation. Anorexia and abdominal distention each was included among the presenting complaints in 26 per cent of the patients. The interval between the onset of symptoms and time of admission to the hospital averages four to five days in most series. In our series an average of seven days had elapsed from onset of symptoms to hospitalization. Symptoms of progressive obstruction in an elderly obese woman who has undergone no previous abdominal surgery strongly suggest gallstone ileus, especially if she has a history of gallbladder disease. Yet a correct preoperative diagnosis is not made frequently. In several recent series, a correct preoperative diagnosis was made 37 to 57 per cent of the time. Preoperative diagnosis was correct in only two of nineteen (10.5 per cent) of our patients in whom this information is available. The physical examination in patients with gallstone ileus is usually difficult because of abdominal distention, muscle guarding, dehydration, obesity, and the presence in many instances of concurrent disease. In several series, the most common signs are abdominal tenderness, abdominal distention, and hyperperistalsis. Jaundice is uncommon. Dehydration is usually present. In our series when data regarding physical signs are available, 79 per cent of patients had abdominal tenderness on examination, 57 per cent bad abdominal distention,
Volume 129, May 197s
Figure 1. Radiograph of abdomen demonstrates pneumobilia.
47 per cent had obstructive bowel sounds, and 6 per cent were jaundiced. Laboratory studies are usually nonspecific but reflect dehydration and electrolyte imbalance. All of the patients in our series with available laboratory data had electrolyte imbalance on admission, 84 per cent had azotemia, and 32 per cent had abnormal results of liver function studies. The abdominal scout film is of major importance in establishing a diagnosis. In 1941, Rigler, Borman, and Noble [3] described four roentgenographic signs in gallstone ileus: (1) air in the biliary tree, which was seen preoperatively in ten of the thirty-four patients (29 per cent) in our series evidence of par(Figure 1); (2) roentgenographic tial or complete intestinal obstruction, which was seen preoperatively in eighteen of thirty-four patients (53 per cent) (Figure 1); (3) direct or indirect visualization of the obstructing stone by means of contrast medium in the intestine, which occurred in twelve of thirty-four patients (35 per cent) (Figure 2); (4) change in position of a previously observed stone, which was seen in two of thirty-four patients (6 per cent). In addition to the scout film, specific studies have been used. Barium contrast x-ray films proved useful in four of the thirty-four patients
555
Day and Marks
(Figure 3), and in one of these the diagnosis was made preoperatively on the basis of hypotonic duodenography that revealed the obstructing gall-
Figure 2. Radiopaque gallstone vtsualked in right lower quadrant.
Figure 3. Reflux of barium through cholecystoduodenal fistuia visualized radiographically.
556
stone. The interval between admission and operation varied between two and four days in several recent series. In our series, an average of 3.2 days elapsed before operation in the thirty-two patients who underwent operation. Most authors recommend enterotomy alone as the initial treatment in the surgical approach to gallstone ileus. Fraser [15], Kirkland and Croce [16], and Malt [17] recommend enterolithotomy and cholecystostomy with stone removal when calculi are palpated in the gallbladder. Many authorities consider additional biliary surgery to be unwise at the time of initial laparotomy. Whether operation in the biliary tree should be undertaken at a later date is a controversial question. Many authors advocate cholecystectomy and repair of the fistula at a second elective procedure as soon after initial operation as possible, citing a 5 per cent risk of recurrent gallstone ileus. Berliner and Burson [IS] stress that, in addition to the risks of recurrent cholecystitis, the incidence of carcinoma of the gallbladder may increase in patients with gallstone ileus. Severe upper gastrointestinal bleeding has also been reported a!+ a late complication of gallstone ileus. Rogers and Carter [19] as well as others state that surgical treatment of cholecystoenteric fistulas should be performed only if warranted by further symptoms of gallbladder disease. In support of this, Raiford [6] and Serino [20] maintain that when the cystic duct is patent the fistula will probably close spontaneously. It has been stressed that even when the fistula remains patent the danger of complications would be small. More recent authors have advocated a more aggressive approach to gallstone ileus, which includes cholecystectomy and fistula repair in conjunction with enterotomy for obstruction. Many undesirable sequelae after enterolithotomy alone could be avoided by a one stage operation. In two separate series, 30 per cent of those treated by enterotomy had further complications related to the gallbladder or fistula. In the series of Cooperman, Dickson, and ReMine [21], two of six patients treated by enterotomy alone had continuing symptoms; a third had recurrence of gallstone ileus one year after the initial episode. The incidence of carcinoma of the gallbladder is allegedly higher in the presence of biliary enteric fistula. Berliner and Burson [18] reviewed fifty-
The Amerkan Journal ol Surgery
Gallstone
seven cases of gallstone ileus with fistula demonstrated at either operation or autopsy. Within this series were eight cases of primary carcinoma of the gallbladder, an incidence of.15 per cent. This is in marked contrast to the 1.12 per cent incidence of carcinoma occurring in all operations on the biliary tract. In our series of thirty-four patients with gallstone ileus, there were two patients (6 per cent) in whom carcinoma of the gallbladder developed. One patient exhibited widespread carcinomatosis (of the gallbladder) at the time of operation for gallstone ileus. In the other, exploration one year after the initial operation for gallstone ileus revealed carcinoma of the gallbladder. At the time of initial operation this latter patient had undergone enterolithotomy and small bowel resection without fistula repair. Berliner and Burson [18] stress that the longer the patient with a fistula survives, the greater the chance of carcinoma occurring. Another undesirable sequela of a patent fistula is cholangitis; its incidence in cholecystoduodenal fistula has been reported as high as 11 per cent. Complications reportedly resulting from cholecystocolonic fistulas, which comprise 14 per cent of all biliary fistulas, have included weight loss (related to a malabsorption syndrome), cholangitis, and empyema of the gallbladder with fatal perforation. Pybus [22] in 1922 resected a cholecystoduodenal fistula and performed cholecystostomy during ileotomy for obstructing gallstones. Holz [23] in 1929 inadvertently entered a cholecystoduodenal fistula while attempting to extract an impacted duodenal stone; since closure of the fistula was necessary, he elected to remove the gallbladder. Welch, Huizanga, and Roberts [24] reported a one stage cholecystectomy, closure of the cholecystoenteric fistula, and relief of the obstruction by enterolithotomy in 1957. Primary repair has been advocated more recently by Warshaw and Bartlett [25], Berliner and Burson [18], Fox [26], and Cooperman, Dickson, and ReMine [21]. The latter reported the largest current series of one stage treatment, with only one death. At the time of this report only twenty-three cases managed in this way have been reported in the English literature. The three patients treated by one stage repair in our series increases this total to twenty-six. Recent data indicate that, with proper patient selection and preoperative preparation, one stage cholecystectomy, fistula repair, and enterolithotomy for gallstone ileus do not result in a significantly higher mortality than does enterotomy alone, even considering the progressive decline in
Volume 129, May 1975
lleus
mortality after enterotomy alone during the past several decades, Prior to 1925, more than.60 per cent of patients with gallstone ileus died. Several recent series show mortality rates of less than 15 per cent and in some series there have been no fatalities. The overall mortality in our series was 21 per cent, operative mortality was 19 per cent, and enterotomy alone had a mortality of 14 per cent. In the largest reported series of elective one stage resections, the operative mortality was 13 per cent, with one death in eight patients; the authors reported the mortality after enterotomy alone also was 13 per cent [21]. The three cases of one stage repair in our series are added to the twenty-three previously reported to substantiate the validity of one stage repair in dealing with the entire disease process during one operative procedure, thus eliminating the known high morbidity after enterotomy alone. Whichever operative procedure is carried out, wound infection has been rather prominent among postoperative complications and reported to be as high as 75 per cent in two separate series. Likelihood of postoperative wound infection is high, considering the obesity of these patients combined with the unavoidable contamination from the content of the obstructed bowel. Summary An analysis of thirty-four patients with gallstone ileus is integrated with a review of the literature on the subject. Surgical treatment was carried out in thirty-two patients, with an overall operative mortality of 19 per cent. Three patients were treated by one stage enterolithotomy, fistula repair, and cholecystectomy without operative mortality, emphasizing the merit of one stage treatment in selected, well prepared patients. A 6 per cent incidence of carcinoma of the gallbladder was noted in this series of patients.
References 1. Martin F: Intestinal obstruction due to gallstones. Ann Surg 55: 725, 1912. 2. Courvoisier LT: Zasurstisch-statistische Beitrage zur Pathologie und Chirurgie der Gallenwege. Leipzig, FCW Vogel, 1890. 3. Rigler LG. Barman CN, Noble JF: Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 117: 1753,194l. 4. Foss HL, Summers JD: Intestinal obstruction from gallstones. Ann Surg 115: 721, 1942. 5. Deckoff SL: Gallstone ileus: a report of 12 cases. Ann Surg 142: 52, 1955.
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6. Raiford TS: Intestinal obstruction caused by gallstones. Am J Surg 104: 383, 1962. 7. Karlin S, Miller WC: Gallstone obstruction of the small bowel. J La State Med Sot 106: 391, 1954. 8. Bretow GW, Crampton RS: Gallstone ileus: a report of 23 cases. Arch Surg 86: 504. 1963. 9. Moore TC, Baker WH: Operative and radiologic relief of gallstone intestinal obstruction. Surg Gynecol Cbstet 116: 189, 1963. 10. Piedad OH, Wels PB: Spontaneous Internal biliary fist&, obstructive and non-obstructive types: twenty year review of 55 cases. Ann Surg 175: 75, 1972. 11. Wakefield EG, Vickers PM, Walters W: Intestinal obstructlon caused by gallstones. Surgery 5: 670, 1939. 12. Gutmann JH: lleus due to migrating gallstones. Am J Surg 30: 548, 1935. 13. Turner GG: A giant gallstone impacted in the colon and causing acute obstruction. Br J Surg 20: 26, 1932. 14. Printen KJ, SafaiaShirazi S: Duodenal obstruction caused by gallstones: report of six cases. Am Surg 39: 688, 1973. 15. Fraser WJ: Intestinal obstruction by gallstone. Br J Surg 42: 210, 1954. 16. Kirkland KC, Croce EJ: Gallstone intestinal obstruction. JAMA 176: 494, 1961.
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17. Malt RA: Experience with recurrent gallstone ileus applied to management of the first attack. Am J Surg 108: 92, 1964. 18. Berliner SD, Burson LC: One-stage repair for cholecystduodenal fistula and gallstone ileus. Arch Surg 90: 313, 1965. 19. Rogers FA, Carter R: Recurrent gallstone ileus. Am J Surg 96: 379, 1958. 20. Serino GS: Gallstone ileus in a 95-year-old woman: a case report with six-year follow-up studies. Geriatrics 14: 257, 1959. 21. Cooperman AM, Dickson ER, ReMine WH: Changing concepts in the surgical treatment of gal&tone ileus: a review of 15 cases with emphasis on diagnosis and treatment. Ann Surg 167: 377, 1968. 22. Pybus FC: A note on two cases of gallstone ileus. Lancet 2: 812, 1922. 23. Holz E: Zur Frage des Gallenstein Ileus. Arch K/in Chir 155: 16, 1929. 24. Welch JS. Huizanga KA, Roberts SE: Recurrent intestinal obstruction due to gallstones. Mayo C/in Proc 32: 628, 1957. 25. Warshaw AL, Bartlett MK: Choice of operation for gallstone intestinal obstruction. Ann Surg 164: 1051. 1966. 26. Fox PF: Planning the operation for cholecystoenteric fistula with gallstone ileus. Surg C/in North Am 50: 93, 1970.
The American Journal of Surgery
