Gallstone ileus accounts for around 25% of mechanical small bowel obstruction in patients over 65 years of age [3
]. A history of biliary symptoms is variable and the obstruction can be intermittent, and so diagnosis is often delayed. Generally patients are women and often are frail and face a post-operative mortality rate of more than 10% [4
Operative management is challenging. Simple enterotomy risks further stones and the potential complications of cholangitis, pancreatitis, and recurrent gallstone ileus. Conversely, cholecystectomy and fistula repair within dense adhesions risk duodenal injury and biliary leak. Both options have an associated mortality in the population in question.
In the case described, it is unclear whether the stone removed at the second laparotomy was in the gallbladder or the bowel lumen at the time of the first operation. Twelve months later, the CT images suggest that a further stone had migrated into the bowel. Our experience demonstrates the importance of inspecting the entirety of the small bowel at the time of the initial laparotomy and illustrates that late recurrence of gallstone ileus, albeit rare, can occur [5
To the best of our knowledge, this is only the third reported case of twice recurrent gallstone ileus [6
]. The recent timing of the two previous reports suggests that the phenomenon is becoming more common, presumably as a result of the increasing age of the population, and prompted us to revisit the evidence comparing enterotomy alone with the one-stage approach in the initial management of the condition.
To date, the largest review of reported cases of gallstone ileus, which consisted of 1001 cases, was published by Reisner and Cohen in 1994 [1
]. The findings are frequently quoted, but the work is limited by the heterogeneity of the reports analyzed. We undertook an electronic literature search to identify all subsequent published comparisons of enterotomy alone versus one-stage repair in the management of gallstone ileus. The terms “gallstone ileus” and “gallstone obstruction” were inserted into PubMed, reference lists were checked, and Scopus (ScienceDirect) was used to identify the citations of key articles. We identified eight comparative studies, of which three comprised at least five patients in each arm. The smaller studies were excluded. Three primary endpoints of operative mortality, operative morbidity, and recurrent biliary disease were considered. Operative complications were defined as those preceding discharge from hospital. Recurrent biliary disease is defined as cholecystitis, choledocholithiasis, cholangitis, recurrent gallstone ileus, pancreatitis, or cholangiocarcinoma during follow-up. The findings of the three studies identified, in addition to those of Reisner and Cohen, are presented in Table .
Comparative studies in the management of gallstone ileus
In their combined series, Reisner and Cohen [1
] published operative mortality rates of 16.9% for one-stage repair and 11.7% for enterolithotomy (P <0.17). The three more recent series also suggest a non-significant excess in operative mortality following one-stage repair. Where reported, comparison of morbidity between the two procedures appears to favor enterotomy and this finding was statistically significant in the study by Doko et al
]. There are no data comparing one- or two-stage repair with simple enterotomy in the context of recurrent gallstone ileus. Interestingly, none of these papers reported an increased frequency of recurrent biliary disease at follow-up. They do, however, illustrate two important points: the high levels of comorbidity in this patient group and the increased operating times associated with one-stage repair [8
These studies all describe small, retrospective, non-randomized series without predetermined follow-up. Given the rarity of the presentation, the inconsistency of pre-operative diagnosis, and the frailty of many patients, formal randomized analysis is unlikely to provide a more definitive set of answers in the future.