Optimal Management of Gall Stone Ileus. Diagnosing by CT Scan and a Limited Operative Approach.

Emil Bota, MBBCh1, Hesham M Souka, MD, FRCS, MBBCh2. 1Diana Princess of Wales Hospital, Grimsby, UK, 2Amina Hospital, Ajman, UAE

Aim: To establish a standard management protocol in the modern era of cross sectional imaging and targeted laparoscopic approach.

Methods: We report 14 patients with gall stone ileus treated over the last 7 years. This is a DGH with 130,000 populations operating on around 300 gall bladders a year. We have a policy operating only on symptomatic gallstones.

Results: All gallstones were more than 2.5 cm in diameter. Twelve patients were females. Average age 73 years (range 46-93). A retrospective history consistent with attacks of cholecystitis was present in twelve patients. Complete intestinal obstruction was the presentation in all 14 patients. All 14 patients had their gallstones recognized on pre-operative CT scan with pneumobilia. Eleven patients have associated significant multiple co-morbidities. All 14 patients had operations to relieve the obstruction by enterotomy, removal of the stone and closure. Three patients had a laparoscopy-assisted delivery of the affected segment, the others had various incisions. All went home well with average length of stay of 16 days (range 4-50), only one patient had post operative wound infection needing prolonged dressings. Two stones were in the jejunum 4 in the ileum and the rest in unspecified location of small intestine. Two stones were impacted at site of obstruction. All patients were well during follow up at least for a year after the operation. One patient died 2 years following surgery at age of 86 (bed ridden, needed 50 days hospital stay before returning to his nursing home). Only one patient had persistent symptoms that can be due to the remaining gall bladder. Only the first patient in the series had concomitant cholecystectomy and postoperative duodenal leakage giving a collection that was treated with NBM, TPN, antibiotics and radiological drainage with no further recurrence.

Conclusion: Therapy should be aiming towards relieving the obstruction not dealing with the gall bladder. Cross sectional study has an important role in establishing the diagnosis and planning laparoscopic assisted surgery. The patients that are likely to develop the condition are those with large cast stones more than 2.5 cm in diameter, associated with co-morbidities and repeated attacks of low-grade cholecystitis.

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