The Surgical Management of Gallstone Ileus in the Era of Laparoscopy

Alejandro Rodriguez-Garcia, MD, Felice Ferri, MD, Cristopher Salzman, MD, Morris E Franklin, MD, FACS. Texas Endosurgery Institute, Tec de Monterrey.

Background
During the last 20 years, the surgical community has witnessed the adoption of laparoscopy for the management of a wide spectrum of intra-abdominal pathologies. Despite this, to date there are very few reported cases of gallstone ileus managed through a totally laparoscopic approach. We will report our experience with this problem and review the available data.

Patients and Methods
From January 1994 to December 2012, a total of 4 patients presented with gallstone ileus at the Texas Endosurgery Institute. We reviewed patient and surgery-related data from a prospectively designed database (Texas Endosurgery Institute Liver and Biliary Procedures Database).

Results
Between 1994 and 2012, we have encountered 3 females and 1 male with gallstone ileus. Clinical details are shown in table 1. All 4 patients were suspected to present gallstone ileus pre-operatively. We decided not to address the gallbladder and cholecystoenteric fistula in one patient due to high risk. Outcomes are detailed in table 2. All patients were discharged before or on post-operative day.

Discussion
Our group originally reported the laparoscopic treatment of gallstone ileus in 1994. Since then, only a handful of reports have become available, with most authors describing laparotomy in this setting. The advantages of laparoscopy – less pain, wound complications, early return to bowel function, and improved cosmesis are well known and have prompted surgeons to employ this approach in almost every conceivable intra-abdominal procedure. Despite this, a recent review by Halabi et al. using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample found that laparoscopy is seldom used when addressing gallstone ileus (10% of a 3268 patient sample) and even then, this group suffered a high conversion rate (53.03%). Patients with gallstone ileus are frequently elderly patients with multiple co-morbidities. We feel that this population is especially well served by a minimally invasive approach, offering relief of obstruction while avoiding potential complications associated with larger abdominal incisions.

In conclusion, laparoscopic enterolithotomy for gallstone ileus is a valid surgical approach. In centers without experience in advanced laparoscopy, a hand-assisted laparoscopic technique might be performed, avoiding prolonged surgical time as well as conversion to laparotomy. We encourage surgeons to consider the minimally invasive approach in most of their patients, and to consider one-stage enterolithotomy and cholecystectomy with fistula closure only in selected low-risk patients.

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