[The therapeutic options in biliary ileus]

Gallstone ileus is a rare, serious condition, requiring emergency surgery. Although most data in the literature confirm the need for a conservative surgical approach, several authors report the one-stage repair of the cholecystoduodenal fistula. The present study deals with seven cases of gallstone ileus operated upon in a 20-year period. The patients were in their seventh decade; three men and four women. All the cases had clinical evidence of intestinal obstruction which was confirmed by radiologic examination, and emergency operations were performed. In three cases the one-stage strategy was used, consisting of enterolithotomy and correction of the bilio-digestive fistula by cholecystectomy and duodenal closure with good results in two cases and one death. In four cases a more conservative strategy was used, treating the intestinal obstruction only and no surgery was performed on the gallbladder or the fistula, having excluded further gallstones. Three patients had no further problems, but one required reoperation because of recurrent cholangitis. The bilio-digestive fistula may close by natural scarring or become a harmless alternative route for biliary drainage.

Enterolithotomy alone usually is advisable in this serious form of intestinal obstruction, confining more major surgery to those cases in which recurrent biliary symptoms develop. However, if there are residual gallstones in the gallbladder, a 'one-stage' procedure is required to prevent recurrent ileus.