Management of Gallstone Ileus Joint Hospital Surgical Grand

Management of Gallstone Ileus Joint Hospital Surgical Grand Round 17 th May, 2008 UCH Cyrus Tse Tak Yin TMH

2 Patients n n n Patient A I. O. OT on Jan 28, 2008 q q q n n n Dx: Gallstone ileus Enterolithotomy + Cholecystectomy + Repair of cholecystoduodenal fistula Discharged on D 7 Patient B I. O. OT on Feb 3, 2008 q Dx: Gallstone ileus q Enterolithotomy q Discharged on D 10

Management of GSI Where are we standing?

Gallstone Ileus (GSI) n n 1 st described by Bartolin in 1654 Misnomer

Gallstone Ileus n n n 1 -4% of mechanical intestinal obstruction Elderly with multiple comorbidities Female: Male 3. 5: 1

Gallstone Ileus n Size n n <2 cm >5 cm

Gallstone Ileus n High peri-operative mortality rate n n 1890: Courvoisier 131 cases n Mortality: approaching 50% Nowadays: n Mortality: 8 -17%

Pathophysiology n Chronic recurrent inflammation + fistula formation

Pathophysiology n Very rarely iatrogenic q Endoscopic sphincterotomy n q Oskam J et al. Acta Chir Belg 1993; 92: 43 -5 Choledochoduodenostomy n Wakefield EG et al. Surgery 1939; 5: 674 -7

Diagnosis n Rigler’s Triad q q q n I. O. Pneumobilia Aberrantly located GS 40 -50% n Rigler LG et al. JAMA 1941; 117: 1753

Diagnosis n Pre-op Dx in <50%

Diagnosis n USG -> 74% q Ripolles T et al. Abdom Imag 2001; 26: 401 -5

Diagnosis n CT -> localization, fistula q Lassandro F et al. AJR 2005; 185: 1159 -1165

Management n Spontaneous resolution reported but uncommon q n Farooq A et al. Emerg Radiol 2007 14: 421 -423 Invariably requires surgery / treatment

Management n n n Resuscitation Optimization Selection

Treatment options n 1 stage operation q n 2 stage operation q q n Enterolithotomy + cholecystectomy + closure of fistula Enterolithotomy **+/- Subsequent cholecystectomy + closure of fistula Others

Controversies n 1 stage q Higher mortality rates (16. 9% vs 11. 7%) Reisner M et al. Am Surg 1994; 60: 441 -6 q Patient factor n q Disease factor n q Comorbidities Local scarring and fibrosis, fistula Surgeon factor n Expertise and experience

Controversies n 2 stage q Complications of cholelithiasis and fistula n Recurrent obstruction 5% Ascending cholangitis / cholecystitis 15% Inherent risks of 2 nd operation n ? risk of CA GB n n q q Bossart et al: 15% incidence with fistula (vs 0. 8%) Clavien et al: Most fistulas well tolerated and close spontaneously without stone

Gallstone Ileus: A Review of 1001 Reported Cases - Reisner RM and Cohen JR The American Surgeon 1994; 60: 441 -446

Reisner and Cohen n “…The procedure should be limited to dealing with the obstruction… Most patient will have no further problems. If symptoms related to the biliary tract return, elective cholecystectomy can be performed. ”

Reisner and Cohen n Multiple stones: 3 -16% Overlooked stones: recurrence in 210% of patients “…This emphasizes the importance of a careful search for more stones throughout the entire GI tract. ”

n “… later biliary complications were prominent in patients treated only by enterolithotomy… a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. ” Clavien PA et al. BJS 1990; 77: 737 -742

n n 63% One stage (12/19) “No significant differences in morbidity or outcomes between the 2 groups” Tan YM et al. Singapore Med J 2004; 45(2): 69 -72

Consensus?

Laparoscopic surgery n Laparoscopic enterolithotomy q q Allen JW et al. Surg Endosc 2003; 17: 352 Ferraina P et al. Surg Laparosc Endosc Percutan Tech 2003; 13: 83 -87

ESWL n n Difficult in localization Successful case of GS in descending colon q Meyenberger C. et al. Gastrointest Endosc 1996; 43: 508 -11

Endoscopic Intervention n Bouveret syndrome n Electrohydraulic lithotripsy q n Bourke MJ et al. Gastrointest Endosc 1997; 45: 521 -3 Mechanical lithotripsy q Moriai T et al. Am J Gastroenterol 1991; 86: 627 -9

Our Experience

TMH Series n 12 cases between Jan 2000 to May 2008

TMH Series - Operation

TMH Series n Pre-op Dx: 4/12 (33. 3%) q q q 2 by AXR 1 by CT 1 by contrast study

Pneumobilia

Ectopic GS

GS + CD fistula

GS in Proximal Ileum

CD fistula

TMH Series - Site q No colon, no Bouveret

TMH Series n ASA 3+: 7/12 (58. 3%) n Median time to OT: 2. 3 days

TMH Series n Immediate to Early Post-op 8 q 1 q 2 q 1 q n - Uncomplicated Recurrence (D 17) Chest infection AF Zero peri-operative mortality

Cholecystitis

GS in terminal Ileum

TMH Series n Enterolithotomy alone (n=9) 7 q 1 - Uncomplicated Recurrent obstruction (D 17) q § q 1 - Acute cholecystitis, 2 nd Stone § q Cholecystectomy + Fistula repair done 1 - Conservative Recurrent cholangitis § Pending cholecystectomy

Conclusion

“In preparing for battle I have always found that plans are useless, but planning is indispensable. ” - Dwight Eisenhower, 1890 -1969 Thank You