Gallstone ileus: One-stage surgery in an elderly patient: One-stage surgery in gallstone ileus

Gallstone ileus (G.I.) is a mechanical bowel obstruction due to impaction of a large gallstone within the bowel and represents an uncommon complication of cholelithiasis. It accounts for 1-4% of all cases of mechanical bowel obstruction, up to 25% in patients over 65 years of age.

A 75 year old male patient was referred to our hospital in March 2009 with clinical signs of bowel obstruction (abdominal pain and distension, post-prandial vomiting, absolute constipation) during the previous 3 days. A plain abdominal film demonstrated dilated bowel loops, air fluid levels and an image of a stone in the inferior left quadrant. Afterwards, diagnosis of Gallstone ileus was made by means of ultrasonography and colonoscopy. The patient underwent emergent laparotomy and a cholecysto-transverse colon fistula was observed. One-stage procedure consisting of enterolithotomy, cholecystectomy and fistula repair was performed. The post-operative course was complicated by a dehiscence of the colic suture with acute peritonitis. Therefore a colostomy was performed, followed by rapid recovery of general clinical conditions.

Surgical treatment for G.I. by cholecysto-enteric fistula is still controversial. Enterolithotomy alone is best suited in all elderly patients with significant comorbidities. One-stage procedure - enterolithotomy, cholecystectomy and fistula repair - should be reserved for young, fit and low risk patients. In our case, mechanical obstruction was associated with a severe cholecystitis with a large fistula between gallbladder and transverse colon.

A "radical" surgical option could certainly be characterized by a significant morbidity.