gallstone ileus review

8/22/2019 Gallstone Ileus Review

1/5

Comparison of Surgical Treatments of Gallstone Ileus: Preliminary Report

Marko Doko, M.D., Ph.D.,1 Mario Zovak, M.D.,1 Mario Kopljar, M.D.,1 Elizabet Glavan, M.D.,1

Neven Ljubicic, M.D., Ph.D.,2 Hrvoje Hochstdter, M.D., M.Sc.1

1Department of Surgery, Clinical Hospital Sestre Milosrdnice, Vinogradska Cesta 29, 10000 Zagreb, Croatia2Department of Internal Medicine, Clinical Hospital Sestre Milosrdnice, Vinogradska Cesta 29, 10000 Zagreb, Croatia

Abstract. Gallstone ileus is an uncommon cause of small bowel obstruc-tion, accounting for only 1% to 4% of all intestinal obstructions. In thegroup of patients over 65 years of age, gallstones cause about 25% of allnon-strangulated obstructions of the small bowel. Gallstone ileus is bur-dened with high mortality rate, ranging from 12% to 18%, and most pa-tients are of advanced age, with many other concomitant diseases that mayincrease the operative risk. The purpose of this study was to compare thetwo investigated surgical procedures: treatment of intestinal obstructionaloneor combined with urgentcholecystectomyand fistula repair.Analysisof 30 patients undergoing operation for gallstone ileus at the Clinical Hos-pital Sestre milosrdnice between 1985 and 2001 is presented. Patients

were treated either for ileus alone (group 1, 11 patients) or as one-stageprocedure with urgent fistula closure (group 2, 19 patients). Operatingtime was significantly longer for the one-stage procedure. Complicationsoccurred in 3 of 11 patients (27.3%) from group 1 and in 11 of 18 patients(61.1%) from group 2 (one tailed, p = 0.043). One patient in group 1 diedand two patients in group 2 died. Urgent fistula repair was significantly

associated with theoccurrence ofcomplications (odds ratio [OR] 12.1, 95%confidence internal [95% CI] 1.2121.5). Simple enterotomy should be theprocedure of choice for patients with gallstone ileus. The one-stage proce-dure including urgent fistula repair should be reserved only for highly se-lected patients with absolute indications.

Gallstone ileus is an uncommon cause of small bowel obstruction,accounting for only 1% to 4% of all intestinal obstructions [1, 2, 3].Gallstone ileus is burdened with high mortality rate, ranging from12% to 18% [2, 4, 5]. However, the treatment of gallstone ileus iscontroversial [3, 4]. Surgical options include either enterotomy andcalculus extraction alone, or in combination with urgent cholecys-tectomy and fistula repair. Because most of these patients are of

advanced age, with many other concomitant diseases that may in-creasethe operative risk, it is of great importanceto assess themostbeneficial surgical approach. Most authors believe that prolongedoperation and additional surgical trauma resulting from fistula re-pair is notbeneficial forthese patients and is potentially harmful [2,3]. Published studies addressing this issue include small series ofpatients, with no definite answer regarding the preferred surgicaloption [3].

The purpose of this study was to compare the outcomes of thetwo investigated surgical proceduresi.e., the treatment of intes-tinal obstruction alone (propulsion, enterotomy or intestinal resec-tion) or the one-stage procedure (treatment of ileus combined withurgent cholecystectomy and fistula repair).

Patients and Methods

Analysis of 30 patients undergoing operation for gallstone ileus atthe Clinical Hospital Sestre milosrdnice between 1985 and 2001is presented. There were 25 womenand 5 men with a median age of73 (range 54 to 91) years.

The following data were acquired from the medical records: gen-der, age, duration of symptoms before admission, previous medical

history, preoperative radiological assessment, duration of preop-erative hospital stay, duration of surgery and intraoperative find-ings, the length of the postoperative hospital stay, and the occur-rence of complications.

Anamnestic information regarding the present illness (durationand type of symptoms) and previous medical history, including in-formation about concomitant illnesses, was taken at the emergencydepartment, and ASA score (American Society of Anesthesiolo-gists Classification System) was determined for every patient. Plainabdominal X-rays were done for all patients, and the signs of intes-tinal obstruction, pneumobilia, and the presence of atypical min-eral shadows in the abdomen were recorded.

The presence of acute inflammation of the gallbladder, choleli-thiasis, or secondary gallstones, as well as thetype of fistula, the site

of obstruction, and the performed procedure (depending on thesurgeons choice) were obtained from the surgeons reports. Allcomplications that occurred during hospitalization were recorded.

Group 1 comprised patients in whom the operation was per-formed for intestinal obstruction only, without fistula repair (11patients) and group 2 comprised patients in whom cholecystectomyand fistula repair was performed (19 patients). In one woman withsmall bowel ileus and pneumobilia confirmed on plain abdominalX-ray, obstruction resolved spontaneously, and the fistula closurealone was performed on the next day as an elective operation. Thispatient was not included in the operative and postoperative analy-sis.

Correspondence to: Mario Kopljar, M.D., e-mail: [email protected]

WORLDJournal of

SURGERY 2 003 by the Societe

Internationale de Chirurgie

World J. Surg. 27, 400404, 2003

DOI: 10.1007/s00268-002-6569-0


2/5

Statistical analysis was performed using the nonparametricMann-Whitney U test for independent samples, Students t-test forindependent samples, chi-square test, Fishers exact probabilitytest, logistic regression, and odds ratios (OD) with 95% confidenceintervals (CI). Results were considered statistically significant forp< 0.05.

Results

Comparison of age, median duration of symptoms, and ASA scoreare presented in Table 1. No statistically significant differenceswere found between the two groups (enterotomy alone vs. con-comitant emergency fistula closure) regarding age, duration ofsymptoms,or mean ASAscore (p > 0.05).Patientspresentedto theemergency department with symptoms of ileus or subileus, whichincluded abdominal cramps, vomiting, abdominal distension, opsti-pation, and the absence of flatus. Median duration of symptoms

before admission to the hospital was 4 (range 110) days.Three patients had positive anamnesis for gallstones, and one

patient had jaundiced sclera. Twelve patients had other concomi-tant illness, 5 (45.5%) patients fromgroup 1 and 7 (38.9%) patientsfrom group 2 (Table 2). This difference was not statistically signifi-cant (chi-square test, p = 0.728).

Preoperative abdominal ultrasound confirmed cholelithiasis inone patient. Plain abdominal X-rays showed signs of intestinal ob-struction in allbut twopatients. In one patient, cholecystoduodenalfistula and gallstone impacted in the duodenum were confirmed atpreoperative gastroscopy, thus providing the preoperative diagno-sis of a rare Bouveret syndrome. Atypical mineral shadow was seenon abdominal radiography in three patients (10%), and pneumo-bilia was noted in six patients (20%). Characteristic Riglers triad

was observed on abdominal radiography in only one pati ent(30.3%). A working diagnosis of gallstone ileus was established in 9patients (30.0%), mesenteric thromboembolism in 2 patients(6.7%), and unspecified ileus in the remaining 19 patients (63.3%).

At operation, fistula was identified in 5 of 11 (45.5%) patientsfrom group 1, all of the cholecystoduodenal type. Among the 19patients from group 2, the fistula was of cholecystoduodenal type in18 patients and the cholecystogastric type in one. Characteristicsof operative findings and surgical procedures are presented inTable 3.

There was statistically significant difference in operating timebetween groups with and withouturgentfistula closure(p = 0.008).

No significant differences between the two groups were found inthe length of stay in the intensive care unit (ICU) or postoperativehospital stay (Table 4).

Complications occurred in 3 of 11 patients (27.3%) from group 1,and in 11 of 18 patients (61.1%) from group 2, after the patient withspontaneous resolution of ileus was excluded because she did notundergo operation for emergency (gallstone ileus) (one tailed, p =

0.043).One patient (9.1%) in group 1 died from myocardial infarction,

and two patients (11.1%) in group 2 died, one from pulmonaryembolism and another from stroke. The difference between thesetwo groups was not statistically significant (one-tailed, p = 0.433;Table 5).

Logistic regression was used to examine the effect of age, dura-tion of symptoms before hospitalization, accurate preoperative di-agnosis of gallstone ileus, operative time, and emergency fistulaclosure on the occurrence of postoperative complications (Table6). Among the examined predictors, only urgent fistula repair wassignificantly associated with postoperative complications. Odds ra-

Table 1. Patient details.

Group 1(n = 11)

Group 2(n = 18)a p value

Age (years) 75 (6588) 71 (5491) 0.753Du ration of symptoms (days) 4 (210) 4 (110) 0.860

ASA score 1b 5 3ASA score 2b 3 11

ASA score 3b 3 5Mean ASA score ( SD) 1.8 (0.87) 2.1 (0.66) 0.316

Group 1: patients in whom only surgery for ileus was performed, with-out fistula repair. Group 2: patients in whom the fistula was repaired.

Values represent medians, with ranges given in parentheses. ForAmerican Society of Anesthesiologists (ASA) score, mean values are givenwith standard deviations in parentheses.

aPatient with spontaneous resolution of ileus was not included.bNumber of patients with that score.

Table 2. Concomitant diseases in patients who presented with gallstoneileus.

Group 1(n = 11)

Group 2(n = 18)a

Arterial hypertension 1 (9.1%) 2 (11.1%)Atrial fibrillation 0 1 (5.6%)Heart failure (compensated) 3 (27.3%) 3 (16.7%)

Ischemic heart disease 1 (9.1%) 1 (5.6%)IDDM 0 1 (5.6%)

Amaurosis 1 (9.1%) 1 (5.6%)Multiple sclerosis 1 (9.1%) 0Tuberculosis 1 (9.1%) 0Inguinal lymphadenopathy 0 1 (5.6%)Summary

Totalb 8 10Number of patients with two

or more concomitant diseases2 2

Number of patients withconcomitant diseases

5 (45.5%) 7 (38.9%)

IDDM: insulin-dependent diabetes mellitus.aPatient with spontaneous resolution of ileus wasnot included (this pa-

tient had no other concomitant illness).bTotal number of concomitant diseases.

Table 3. Operative findings and procedures in two groups of patientswith gallstone i leus.

Group 1 (n = 11) Group 2 (n = 19)

Acute cholecystitis 0 4 (21.1%)Residual stones 0 3 (15.8%)Site of obstruction

Ileum 9 (81.1%) 10 (66.7%)Jejunum 1 (9.1%) 3 (15.8%)Duodenum 0 1 (5.3%)Unspecified 1 (9.1%) 4 (21.1%)No obstructiona 0 1 (5.3%)

Bowel operationb

Resection and anastomosis 2 (18.2%) 3 (15.8%)

Enterotomy 7 (63.6%) 15 (78.9%)Propulsion 2 (18.2%) 0

aOne female patient with spontaneous resolution of ileus one day be-fore surgery.

bFistula repair alone was performed in the patient with spontaneousresolution of ileus.

401Doko et al.: Surgical Treatments of Gallstone Ileus


3/5

tiofor theoccurrence of postoperativecomplication(s) after urgentfistula repair was 12.1 with 95% confidence interval 1.2121.5 (p =0.046).

Discussion

Gallstone ileus is a rare cause of intestinal obstruction occurringpredominantlyin elderly patients. Although patients as young as 13years of age have been diagnosed with gallstone ileus [5], most areof advanced age [6, 7]. In the group of patients over 65 years of age,gallstone ileus accounts for about 25% of all nonstrangulated ob-structions of the small bowel [24].

Symptoms are often characteristic of intestinal obstruction [7],

but they tend to improve only to worsen again. This so-called tum-bling phenomenon is caused by migration of gallstones and theirimpaction distally in the intestine [2]. The characteristic radiologi-cal sign of gallstone ileus is Riglers triad: small bowel obstruction,pneumobilia, and an atypical migrating mineral shadow on plainX-ray of theabdomen [4]. However, exact preoperativediagnosis isestablished in only 31% to 48% of patients [3, 8]. In most patientsthe correct diagnosis is not established until surgery. In this study,preoperative diagnosis of gallstone ileus was established in only30% of patients. Plain abdominal X-ray was diagnostic in 8 pa-tients, revealing either an atypical mineral shadow in theprojectionof the terminal ileum or the presence of air in the biliary vessels

(pneumobilia). An upper gastrointestinal series, ultrasound, andCT may also be valuable in the diagnostic process [4, 5, 9].

Gallstones enter the intestinal tract through a fistula formed be-

tween gallbladder and duodenum, stomach, or colon [3]. Cholecys-toduodenal fistula is the most frequent form, found in approxi-

mately 83% of patients with gallstone ileus, while other fistulas are

rare [10]. In this research, one patient with cholecystogastric fistula

was observed.The most common site of gallstone impaction is the terminal il-

eum, but other sites of obstruction have also been described, such

as the jejunum, colon, or even Meckels diverticulum [8, 9, 11]. Inthis study, the ileum was the most common site of obstruction

(63.3%), followed by the jejunum (13.3%), and the duodenum

(3.3%). Obstruction at the level of the pylorus or duodenum called

Bouverets syndrome manifests with symptoms of high intestinalobstruction. This obstruction can easily be visualized by means of

upper gastrointestinal endoscopy, which also enables extraction of

gallstone(s) without the need for laparotomy. In this series of pa-

tients, there was a single patient with cholecystoduodenal fistulawho presented with Bouverets syndrome. The treatment of this

patientconsisted of enterotomy with calculus extraction and fistularepair.

Gallstoneileus occurs in women more frequently than in men [3,7, 8]. In some published reports this ratio is as high as 16:1 butgenerally women patients are encountered 3 to 5 times more oftenthan men [2].

Many patients with gallstone ileus also have concomitant dis-eases that increase operative risk [2,3]. Because gallstoneileus rep-resents an urgent surgical condition, accompanied often with fluidand electrolyteimbalance, the preferred surgical procedure usuallyconsists of enterotomy and the extraction of calculus [13, 6]. Ad-ditional fistula repair significantly prolonged the duration of sur-gery in this research, which may increase the risk for postoperativecomplications [12, 13].

Some authors claim that possible complications of unattainedfistula do not justify simple enterotomy or resection for treatingileus alone [14, 15]. Major reasons for performing the one-stageprocedure are these: the recurrence of gallstone ileus due to over-looked residual gallstones, cholangitis and an increased incidenceof gallbladder carcinoma [3]. However, these studies presented theresults of urgent fistula repair withoutcomparing them to true con-trol groups (in each study, there were only 2 patients in the controlgroup that underwent enterotomy alone), making the comparisonof morbidity and mortality difficult. It is, naturally, possible toachieve lower morbidity andmortalityratesfor urgent fistula repaircompared with the results from other studies, but it still remains toprove that these will not be differentfrom the results of enterotomyalone in the same study.

As ileus occurs some time after a gallstone has passed into thedigestive system, subacute inflammation of the gallbladder shouldbe expected at surgery. Any anastomosis and suturing in such aninflamed area, although successful in some patients, is not wise forthe majority. Large studies support this standpoint [13, 6, 12, 13]andrevealgreater mortalitywhen fistula repairwas performed dur-ing urgent operation for ileus [2].

We strongly believe that the mortality rate of 16.9% for the one-stage procedure, compared to 11.7% for enterotomy alone, as re-ported in a meta-analysis of 1001 patients [2], does not justify ur-gent fistula repair. In our research 12 (40%) patients had someother concomitant illness, and 4 (13%) patients had two or more

Table 4. Comparison of the duration of surgery, length of stay in theintensive care unit (ICU), and postoperative hospital stay.

Group 1(n = 11)

Group 2(n = 18)a p Value

Duration of surgery (minutes) 40 (3050) 140 (90170) 0.008*Length of stay in ICU (hours) 0 (0144) 113 (0588) 0.062Postoperative hospital stay (days) 14 (330) 15 (155) 0.367

Values represent medians, with ranges given in parentheses.aPatient with spontaneous resolution of ileus was not included.*Statistically significant difference.

Table 5. Postoperative complications.

Group 1 (n = 11) Group 2 (n = 18)a

Wound infection 2 (18.2%) 2 (11.1%)Wound dehiscence 0 2 [2] (11.1%)Myocardial infarction 1b (9.1%) 1 (5.6%)Pulmonary embolism 1b (5.6%)Thrombophlebitis 0 1 (5.6%)Stroke 0 1b (5.6%)Embolism of the right

brachial artery

0 1 (5.6%)

Bronchopneumonia 0 3 [1c] (16.7%)Postoperative ileus 0 3 (16.7%)Number of patients with

two or more complications0 4 (22.2%)

Number of reoperated patients 0 3 (16.7%)Total complications 3 (of 3 patients) 15 (of 11 patients)d

In-hospital mortality 1 (9.1%) 2 (11.1%)

Percentages are given in parentheses. Numbers in brackets representthe number of reoperated patients.

aPatient with spontaneous resolution of ileus was not included.bCause of death.cTracheotomia.dFour patients had 2 complications.

402 World J. Surg. Vol. 27, No. 4, April 2003


4/5

concomitant diseases. Large meta-analysis revealed that 80% ofpatients with gallstone ileus were treated by enterotomy alone,whereas fistula was repaired in 11% of patients; five percent of pa-tients required no surgery and in 1.3% of patients gallstones passed

spontaneously per rectum [2]. We also recorded one patient withspontaneous evacuation of gallstones without the need for urgentsurgery.

Intraoperative findings have a great influence on the choice ofsurgery [3]. Acutely inflamed or gangrenous gallbladder, as well asresidual stones in the gallbladder, may warrant the one-stage pro-cedure with definitive fistula repair [3]. It should be rememberedthat many of these patients are in poor general condition with signsof dehydration, shock, or even peritonitis, and so the main effort oftreatment must be the relief of obstruction and preservation of life[3]. Results from this study showed that urgent fistula repair signifi-cantly prolonged operating time and, among several other predic-tors presented in Table 6, urgent fistula repair was independentlyand significantly associated with an increased rate of complica-

tions.This study included a limited number of patients, without post-

operative long-term follow-up. However, the difference in earlypostoperative morbidity was much greater after urgent fistula re-pair (27.3% versus 61.1%). Assuming that the more extensive andlonger operative procedure would naturally result in greater num-ber of complications, this difference was considered statistically sig-nificant (one-tailed, p = 0.043), and thereby no justification for ur-gent fistula repair was found.

Based on these results and the results of other large publishedstudies that included long-term follow-up [2, 3, 6], we believe thatsimple enterotomy should be the procedure of choice for patientswith gallstone ileus. Complications related to unattained fistula arerare, and only 10% of patients eventually require reoperation for

conditions related to the biliary tract [2, 3]. The one-stage proce-dure including urgent fistula repair should be reserved only forhighly selected patients with absolute indications (acute cholecys-titis and/or gangrene of the gallbladder or residual stones), due toincreasedrisk of complications andlow rate of correctpreoperativediagnosis. Further larger prospective studies should be performedto accurately assess the best operative approach to these patients.

Rsum. Lilus biliaire est une cause peu frquente docclusion delintestin grle, reprsentant seulement 14% de toutes les occlusionsintestinales. Dans le groupe de patients gs de 65 ans ou plus, les calculssont responsables denviron 25% de toutes les occlusions sansstrangulation de lintestin grle. Lilus biliaire est associ une mortalit

leve allant de 12% 18%. La plupart des patients sont trs gs et parconsquent, ontune co-morbidit importante ce qui pourraientaggraver lerisque opratoire. Le but de cette tude a t de comparer deux tactiquesthrapeutiques : traitement de locclusion intestinale seule ou combineavec une cholcystectomie en urgence et une rparation de la fistule. On a

analys les rsultats de 30 patients oprs pour ilus biliaire lhpitalSestre milosrdnice entre 1985 et 2001. Les patients ont t traits soitpour leur occlusionseule(groupe 1, 11 patients) ou parune intervention enun temps comportant aussi le traitement de la fistule (groupe 2, 19patients). Le temps opratoire a t significativement plus long dans letraitement en un temps. On a not descomplications chez 3 des11 patients(27.3%) du groupe 1 et chez 11 des 18 patients (61.1%) du groupe 2 (testunilatral, p = 0.043). Un patient est dcd dans le groupe 1 alors quedeux sont dcds dans le groupe 2. La rparation de la fistule en urgencea t associe significativement plus de complications (rapport de cte:12.1, 95% ICCI 1.2121.5). Une simple entrotomie doit tre le procd dechoix pour les patients oprs dun ilus biliaire. Une intervention en unseul temps doit tre rserve pour des patients slectionns et avec desindications trs prcises.

Resumen. El leo biliar es una rara causa de obstruccin de intestinodelgado, representando slo el 14% de todos los cuadros oclusivos. Sin

embargo, en pacientes mayores de 65 aos, losclculosbiliaresconstituyenel 25% de todas las obstrucciones, excepcin hecha de las producidas porestrangulacin. El leo biliar cursa con mortalidad alta que oscila entre el12% y 18%, superndose estas cifras en pacientes de edad avanzada y conenfermedades concomitantes. Comparar dos procedimientos quirrgicos:eltratamiento exclusivo de la obstruccin intestinal y la asociacin a dichotratamiento de unacolecistectomade urgencia conreparacin de la fstulacolecisto-entrica. Se efecta un anlisis de 30 pacientes intervenidos porleo biliarentre 1985y 2001en el Hospital Clnico Sestremilosrdnice. Enlos pacientes del grupo I (n = 11) se efectu exclusivamente unaenterotoma desobstructiva. En el grupo II (n = 19) se realiz junto a laintervencin desobstructiva una colecistectoma y cierre de la fstulaentrica. La duracin de la intervencin fuems prolongada en el grupo II.Sobrevinieron complicaciones en 3/11pacientes delgrupoI (27.3%)y 11/18del grupo II (61.1%), p = 0.043. En el grupo I falleci un paciente y otro enel grupo II. El tratamiento urgente de la fstula colecistoentrica curs conuna mayor tasa de complicaciones (OR 12.1; 95% CI: 1.2121.5). La

enterotoma simple constituye el tratamiento de eleccin del leo biliar;slo en casos de absoluta necesidad y en pacientes bien seleccionadospuede realizarse adems de urgencia, una colecistectoma y cierre de lafistula bilio-entrica.

References

1. VanLandingham SB, Broders CW. Gallstone ileus. Surg. Clin. NorthAm. 1982;62:241247

2. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reportedcases. Am. Surg. 1994;60:441446

3. Rodriguez-Sanjuan JC, Casado F, Fernandez MJ, et al. Cholecystecto-my and fistula closure versus enterolithotomy alone in gallstone ileus.Br. J. Surg. 1997;84:634637

Table 6. Logistic regression, odds ratios, and confidence intervalsanalysis of postoperative complications.

Constant AgeDuration ofsymptoms

Accuratepreoperativediagnosis

Emergencyfistularepair

Operativetime

Logistic regressionEstimate 0.815 0.029 0.093 1.472 2.491 0.024SE 3.827 0.046 0.262 1.074 1.178 0.019

T 0.213 0.621 0.354 1.370 2.114 1.270p Value 0.833 0.541 0.727 0.184 0.046 0.217

OR and 95% CIOR 1.03 0.91 0.23 12.07 0.9895% CI low 0.94 0.54 0.03 1.20 0.9495% CI high 1.13 1.52 1.88 121.51 1.01

SE: standard error;T: parameterestimate divided by standard error;OR: oddsratio; 95%CI low: lower marginof the 95% confidence interval range;95% CI high: higher margin of the 95% confidence interval ranges.

403Doko et al.: Surgical Treatments of Gallstone Ileus


5/5

4. Coulier B, Coppens JP, Broze B. Computed tomographic diagnosis ofbiliary ileus. J. Belg. Radiol. 1998;81:7578

5. Grassi R, Pinto A, Rossi E, et al. Nine consecutive patients with gall-stone ileus. Personal experience. Radiol. Med. 1998;95:177181

6. Lobo DN, Jobling JC, Balfour TW. Gallstone ileus: diagnostic pitfallsand therapeutic successes. J. Clin. Gastroenterol. 2000;30:7276

7. Sciacca P, Benini B, Borrello M. Mechanical occlusion of the small in-testines by gallstones. Our experience. Minerva. Chir. 1997;52:3944

8. Schutte H, Bastias J, Csendes A, et al. Gallstone ileus. Hepatogastro-enterology 1992;39:562565

9. Caselitz M, Gebel M, Bleck J, et al. Atypical gallstone ileus: radiologicand sonographic findings. Ultraschall. Med. 1999;20:7880

10. Freitag M, Elsner I, Gunl U, et al. Clinical and imaging aspects of gall-stone ileus. Experiences with 108 individual observations. Chirurg1998;69:265269

11. Nakamoto Y, Saga T, Fujishiro S, et al. Gallstone ileus with impactionat the neck of a Meckels diverticulum. Br. J. Radiol. 1998;71:13201322

12. Hardy KJ, Fletcher DR, Jones RM. One hundred liver resections in-cluding comparison to non-resected liver-mobilized patients. Aust.N.Z. J. Surg. 1998;68:716721

13. Miyagawa S, Makuuchi M, Kawasaki S, et al. Criteria for safe hepaticresection. Am. J. Surg. 1995;169:589594

14. Sfairi A, Patel JC. Gallstone ileus: plea for simultaneous treatment ofobstruction and gallstone disease. J. Chir. 1997;134:5964

15. Zuegel N, Hehl A, Lindemann F, et al. Advantages of one-stage repairin case of gallstone ileus. Hepatogastroenterology 1997;44:5962

404 World J. Surg. Vol. 27, No. 4, April 2003

gallstone ileus review

Documents