Br. J. Surg. 1990, Vol. 77, July, 737-742

P.-A. Clavien, J. Richon, S. Burgan and A. Rohner Department of Surgery, Clinic of Digestive Surgery, University Hospital, 12 1 1 - Geneva 4, Switzerland Correspondence to: Dr P.-A. Clavien, Department of Surgery, University of Toronto, Room 1225, 600 University Avenue, Toronto, Ontario M 5 G 1x5, Canada

Gallstone ileus Thirty-seven patients (33 women and four men, median age 78 years) were operated on for gallstone ileus over a 12-year period with a median follow-up of 6-2 years. Twenty-three patients (62 per cent) had serious concomitant diseases. Plain abdominal radiographs performed at admission were diagnostic in only I7 patients (46 per cent) and other procedures such as ultrasonography, gastrointestinal contrast studies and computed tomographic scan were required in ten patients (27 per cent). The diagnosis was made before operation in 27 patients (73 per cent) but in only 17 (46 per cent) at admission. Obstructing stones were located in the terminal ileum in 27 patients (73 per cent), in the proximal ileum or jejunum in five ( I 4 per cent), in the duodenum in two (5per cent), and in the colon in three (8 per cent). In six instances (16 per cent), more than one stone was involved. Cholecystduodenal fistula was the most frequent fistula type (n = 25, 68 per cent),followed by cholecystcolonic (n = 2, 5 per cent) and cholecystduodenocolonic (n=2, 5 per cent) types. The site of the fistula was not established in the other eight instances. A one-stage procedure consisting of the removal of the impacted stone, fistula repair and cholecystectomy was performed in eight patients, two of whom died. A second group of six patients underwent a two-stage procedure consisting of enterolithotomy followed by elective biliary surgery, with no mortality. Removal of impacted stones was the only surgical treatment in the remaining 23 patients, with five deaths. Operative mortality and morbidity rates associated with the initial procedure did not differ significantly among the three therapeutic groups, which were comparable in terms of patient age, associated concomitant diseases and APACHE 11 score. However, later biliary complications were prominent in patients treated only by enterolithotomy. These results support the view that a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. When local or surgical conditions argue against a one-stage procedure, biliary surgery at a second stage should be considered, if residual stones are present. In poor risk patients, non-operative methods should be considered. Keywords: Gallstone ileus, radiology, treatment, biliary surgery, recurrence

Longevity in Western countries has probably increased the prevalence of gallstone ileus. In the past, few authors have reported more than one case per year'-5; however, in recent years, we have encountered more than three cases per year at the University Hospital of Geneva. Gallstone ileus is a troublesome surgical disorder. It is often misdiagnosed and carries a significant rate of complications and a mortality rate ranging between 12 and 27 per cent in most series reported in the past 30 years'.3-12; its danger reflects the advanced age of patients and the high incidence of severe concomitant diseases. Some authors recommend surgical removal of the obstructing stone from the gut and avoid biliary surgery so as to reduce operative time and postoperative mortality rate2*8.'3-'6. On the other hand, some authors emphasize that fistula repair and cholecystectomy should also be undertaken whenever possible, either during the initial procedure4*''-I9 or at a second staged operationg. The purpose of the present study is to review the clinical syndrome, the risk factors, the radiological and operative findings and the postoperative course of patients with gallstone ileus in a region of high incidence. The various surgical procedures will be evaluated in terms of morbidity, mortality and incidence of recurrent biliary symptoms. All patients alive at the time of the survey were re-examined at a median interval of 6.2 years (range 2-15 years) from their initial presentation.

Patients, methods and results From January 1976 to December 1987 thirty-seven patients were treated for gallstone ileus at our hospital, representing 1.7 per cent of 2197 patients admitted with mechanical bowel obstruction during that period. The incidence rose from 0.7 per cent in the age group under 70 years to 4.8 per cent in older patients (P