Surgical Management of Gallstone Ileus: Approach, Outcome, Case Report, and Literature Review

Gallstone ileus (GSI) is a condition caused by migrating gallstones lodged in the terminal ileum. Stone migration results from fistula formation, typically between the gallbladder and duodenum, termed a cholecystoduodenal fistula. This mechanical obstruction has high mortality and requires prompt intervention. This discussion focuses on two GSI cases caused by cholecystoduodenal fistula managed by the surgical removal of the mechanical obstruction and a conservative approach to the fistula. Patient 1 is a 51-year-old male with no significant past medical history. After radiological imaging and laboratory findings raised concern for cholecystoduodenal fistula, the patient underwent a diagnostic laparoscopy with small bowel resection. The second patient is a 74-year-old female with a past medical history of hypertension, myocardial infarction, and laparoscopic uterine lift. The patient underwent diagnostic laparoscopy, lysis of adhesions, mini-laparotomy, and segmental small bowel resection with primary anastomosis. Many factors lead to gallstone formation, including gender, genetics, ethnicity, etc. Fistulas are formed from chronic inflammation and tissue necrosis from gallstone pressure on surrounding tissue. Classic radiologic findings of GSI are pneumobilia, bowel obstruction, and gallstones outside the gallbladder. The most common approach to GSI management is solely relieving the mechanical obstruction by an enterotomy proximal to the obstruction, associated with reduced mortality. Both patients had good outcomes which we attributed to our surgical removal of the small bowel obstruction and a non-operative approach to the cholecystoduodenal fistula.