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A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy
CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 3 (2012) 12–15
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy Yoshihiro Shioi a,∗ , Shuji Kawamura a , Kiminori Kanno a , Yutaka Nishinari a , Kousei Ikeda b , Akihiro Noro b , Fumishi Kooka b a b
Department of Surgery, Iwate Prefectural Esashi Hospital, 5-23 Nishiodori, Esashi, Oshu, Iwate 023-1103, Japan Department of Gastroenterology, Iwate Prefectural Esashi Hospital, 5-23 Nishiodori, Esashi, Oshu, Iwate 023-1103, Japan
a r t i c l e
i n f o
Article history: Received 28 June 2011 Accepted 14 July 2011 Available online 14 October 2011 Keywords: Cholecystoduodenal fistula Endoscopy Gallstone Ileus Enterolithotomy
a b s t r a c t INTRODUCTION: Gallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported. PRESENTATION OF CASE: We report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy. DISCUSSION: Laparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract. CONCLUSION: Endoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery. © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction Gallstone ileus is a relatively rare cause of mechanical intestinal obstruction. The most frequent mechanism by which this occurs is by migration of a gallstone through a cholecystoduodenal fistula.1 Gallstone ileus, a disease of elderly patients with cholelithiasis, has a high morbidity and rate of complications. Treatment of gallstone ileus by enterolithotomy alone is the gold standard for management of patients with severe concomitant disease.2,3 The associated cholecystoduodenal fistula occasionally closes spontaneously. We report here a case of gallstone ileus in which spontaneous closure of the cholecystoduodenal fistula was observed endoscopically after laparoscopic enterolithotomy alone. 2. Presentation of case A 51-year-old Japanese man presented to our hospital with a 10-day history of abdominal pain, distension, nausea, and vomiting. He had a history of hypertension and diabetes mellitus. He had also been admitted to a hospital 5 months previously for an episode of cholecystocholedocholithiasis. At that time, two stones had been detected in the common bile duct by endoscopic retrograde
∗ Corresponding author. Tel.: +81 197 35 2181; fax: +81 197 35 0530. E-mail address: [email protected] (Y. Shioi).
cholangiography (ERC) and those had been removed by endoscopic sphincterotomy. No other intervention had been performed because he hoped to avoid further treatment. On examination, there was abdominal distension and right lower abdominal tenderness. Laboratory studies showed a white cell count of 9290 cells/L; C-reactive protein of 3.18 mg/dL; and HbA1c of 6.9%. An abdominal X-ray film showed dilated loops of small intestine and air in the gallbladder. An abdominal CT scan demonstrated that a calcified 3 cm oval gallstone had impacted in the terminal ileum, causing upper gastrointestinal dilatation. Pneumobilia and cholecystoduodenal fistula were confirmed (Fig. 1). A diagnosis of gallstone ileus was made, and emergency laparoscopy-assisted enterolithotomy was performed on the following day. A 12 mm blunt trocar and two additional ports were positioned below the umbilicus and in the right and left lower abdomen, respectively. A gallstone was found to have impacted in the terminal ileum, the small intestine being dilated proximally. Because there were severe adhesions around the gallbladder, liver, omentum and peritoneum, fistula repair was not undertaken, only laparoscopy-assisted enterolithotomy being performed (Fig. 2). A minilaparotomy was performed by extending the midline incision below the umbilicus by 6 cm, and the gallstone was removed from the ileum through the extended incision. Longitudinal enterotomy was performed to extract the brown gallstone, which measured 39 mm × 28 mm, and the incision closed transversely using an Albert–Lembert suture. The patient resumed oral intake on postoperative day 5 and was discharged on
2210-2612/$ – see front matter © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijscr.2011.07.012
CASE REPORT – OPEN ACCESS Y. Shioi et al. / International Journal of Surgery Case Reports 3 (2012) 12–15
13
Fig. 1. Computed tomography findings. (a) A gallstone measuring 3 cm in the terminal ileum (arrow), (b) pneumobilia (arrowhead) and cholecystoduodenal fistula (arrow).
Fig. 2. Intraoperative findings. (a) Severe adhesions of gallbladder, omentum, and duodenum. (b) Laparoscopy-assisted enterolithotomy.
postoperative day 14 in spite of wound infection. One week after removal of the gallstone, esophago-gastro-duodenoscopy (EGD) revealed an erythematous cholecystoduodenal fistula with a white coating in the superior duodenal angulus (Fig. 3a). Two weeks later, an EGD confirmed that the fistula had closed spontaneously
(Fig. 3b) and an ERC performed simultaneously revealed that the cholecystoduodenal fistula had connected the infundibulum of the gallbladder to the second part of the duodenum (Fig. 4). No symptoms or liver dysfunction occurred during the 6-month follow up.
Fig. 3. Endoscopic findings. (a) One week after surgery: the inflamed orifice of the cholecystoduodenal fistula (arrow) in the superior duodenal angulus. (b) Two weeks after surgery: the cholecystoduodenal fistula (arrow) had closed.
CASE REPORT – OPEN ACCESS 14
Y. Shioi et al. / International Journal of Surgery Case Reports 3 (2012) 12–15
Fig. 4. Endoscopic retrograde cholangiography revealing that the cholecystoduodenal fistula had connected the infundibulum of the gallbladder to the second part of the duodenum.
3. Discussion Gallstone ileus, a rare complication of cholelithiasis, is a relatively rare cause of mechanical bowel obstruction, being found in 1–4% of cases.4–6 Because gallstone ileus is mainly a condition of elderly patients, there is a high rate of morbidity due to concomitant disease, resulting in a high mortality rate of from 6.7 to 22.7%.2–4,7 The pathophysiology of gallstone ileus is as follows. Acute or chronic cholecystitis associated with cholelithiasis, together with pressure from gallstones, causes inflammation and adhesions, facilitating the formation of a cholecystoenteric fistula.8 Cholecystoduodenal fistula is the most common type of cholecystoenteric fistula, less frequent types being cholecystocolonic and cholecystduodenocolonic.4,5 The diagnosis of gallstone ileus is still missed or delayed, an accurate preoperative diagnosis being made in only 77% of cases.7 The classical radiological triad for this diagnosis is pneumobilia, the presence of an ectopic gallstone and mechanical bowel obstruction.9 Advanced diagnostic imaging technology, such as multidetector computed tomography, allows direct visualization of cholecystoenteric fistulae, leading to a more precise diagnosis.10 There are three options for the surgical management of gallstone ileus. The first option is enterolithotomy with stone extraction alone. The second is a two-stage procedure, namely enterolithotomy followed by delayed elective cholecystectomy and fistula repair. The third is a one stage procedure, namely enterolithotomy, cholecystectomy and fistula repair.1 The selection of surgical procedure depends largely on the clinical status of the patient, enterolithotomy alone being advised if the patient is elderly and there are concomitant diseases.2,3,11,12 Definitive cholecystectomy and fistula closure is associated with a prolonged operative time and higher complication and mortality rates. Our patient was severely dehydrated and malnourished because he had taken nothing by mouth for 10 days. In addition, laparoscopy revealed severe adhesions around the gallbladder. Accordingly, we selected enterolithotomy alone in preference to one-stage surgery. Laparoscopy-assisted enterolithotomy for gallstone ileus, as used in the present case, allows simultaneous direct
diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract. We recommend laparoscopyassisted enterolithotomy for both diagnosis and treatment because it is less invasive than open surgery, and therefore results in fewer major complications.13 Patients with gallstone ileus who are elderly and have associated disease would particularly benefit from a laparoscopic approach. This case report describes diagnosis by endoscopy of spontaneous closure of a cholecystoduodenal fistula. Endoscopy can diagnose the location, status and circumference of a fistula by direct visualization. A few previous reports have described spontaneous closure of cholecystoduodenal fistulae.2,6 The procedure of enterolithotomy alone occasionally causes biliary complication such as chronic cholangitis leading to hepatic insufficiency, and the development of biliary carcinoma,6 but spontaneous closure of cholecystoduodenal fistulae may result in fewer such complications. Raf and Spangen recommended that delayed elective cholecystectomy and fistula repair should be performed during the quiet period 3–6 months after enterolithotomy for gallstone ileus.6 The time from onset of the gallstone ileus to closure of cholecystoduodenal fistula has not often been reported. Confirmation of fistulous closure by endoscopy after laparoscopy-assisted enterolithotomy may occasionally result in this minimally invasive procedure averting the need for biliary surgery. A search of articles published in English revealed that the process of spontaneous fistulous closure has rarely been described. Confirmation of fistula closure by the morphological appearance on endoscopy may contribute to more appropriate treatment in individual cases. 4. Conclusion We have presented here a case of gallstone ileus in which a cholecystoduodenal fistula had closed spontaneously by 2 weeks after enterolithotomy alone. We propose that the necessity for cholecystectomy and fistula repair should be assessed earlier than previously considered, because spontaneous closure of a fistula can occur within a month of onset of gallstone ileus. Conflict of interest statement The authors have no conflict of interests to declare. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. Funding None. Author contributions Yoshihiro Shioi contributed to data collections, data analysis, and writing. Shuji Kawamura, Kiminori Kanno, Yutaka Nishinari, Kousei Ikeda, Akihiro Noro, and Fumishi Kooka contributed to data collections. Acknowledgements This study had no source of funding.
CASE REPORT – OPEN ACCESS Y. Shioi et al. / International Journal of Surgery Case Reports 3 (2012) 12–15
References 1. Beuran M, Ivanov I, Venter MD. Gallstone ileus—clinical and therapeutic aspects. J Med Life 2010;3:365–71. 2. Lobo DN, Jobling JC, Balfour TW. Gallstone ileus: diagnostic pitfalls and therapeutic successes. J Clin Gastroenterol 2000;30:72–6. 3. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg 1994;60:441–6. 4. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg 1990;77:737–42. 5. Pavlidis TE, Atmatzidis KS, Papaziogas BT, Papaziogas TB. Management of gallstone ileus. J Hepatobiliary Pancreat Surg 2003;10:299–302. 6. Raf L, Spangen L. Gallstone ileus. Acta Chir Scand 1971;137:665–75. 7. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007;31:1292–7.
15
8. Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: a review. Mt Sinai J Med 2006;73:1132–4. 9. Rigler L, Borman C, Noble J. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941;117:1753–9. 10. Lassandro F, Romano S, Ragozzino A, Rossi G, Valente T, Ferrara I, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. Am J Roentgenol 2005;185:1159–65. 11. Doko M, Zovak M, Kopljar M, Glavan E, Ljubicic N, Hochstadter H. Comparison of surgical treatments of gallstone ileus: preliminary report. World J Surg 2003;27:400–4. 12. Riaz N, Khan MR, Tayeb M. Gallstone ileus: retrospective review of a single centre’s experience using two surgical procedures. Singapore Med J 2008;49: 624–6. 13. Moberg AC, Montgomery A. Laparoscopically assisted or open enterolithotomy for gallstone ileus. Br J Surg 2007;94:53–7.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy Yoshihiro Shioi a,∗ , Shuji Kawamura a , Kiminori Kanno a , Yutaka Nishinari a , Kousei Ikeda b , Akihiro Noro b , Fumishi Kooka b a b
Department of Surgery, Iwate Prefectural Esashi Hospital, 5-23 Nishiodori, Esashi, Oshu, Iwate 023-1103, Japan Department of Gastroenterology, Iwate Prefectural Esashi Hospital, 5-23 Nishiodori, Esashi, Oshu, Iwate 023-1103, Japan
a r t i c l e
i n f o
Article history: Received 28 June 2011 Accepted 14 July 2011 Available online 14 October 2011 Keywords: Cholecystoduodenal fistula Endoscopy Gallstone Ileus Enterolithotomy
a b s t r a c t INTRODUCTION: Gallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported. PRESENTATION OF CASE: We report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy. DISCUSSION: Laparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract. CONCLUSION: Endoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery. © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction Gallstone ileus is a relatively rare cause of mechanical intestinal obstruction. The most frequent mechanism by which this occurs is by migration of a gallstone through a cholecystoduodenal fistula.1 Gallstone ileus, a disease of elderly patients with cholelithiasis, has a high morbidity and rate of complications. Treatment of gallstone ileus by enterolithotomy alone is the gold standard for management of patients with severe concomitant disease.2,3 The associated cholecystoduodenal fistula occasionally closes spontaneously. We report here a case of gallstone ileus in which spontaneous closure of the cholecystoduodenal fistula was observed endoscopically after laparoscopic enterolithotomy alone. 2. Presentation of case A 51-year-old Japanese man presented to our hospital with a 10-day history of abdominal pain, distension, nausea, and vomiting. He had a history of hypertension and diabetes mellitus. He had also been admitted to a hospital 5 months previously for an episode of cholecystocholedocholithiasis. At that time, two stones had been detected in the common bile duct by endoscopic retrograde
∗ Corresponding author. Tel.: +81 197 35 2181; fax: +81 197 35 0530. E-mail address: [email protected] (Y. Shioi).
cholangiography (ERC) and those had been removed by endoscopic sphincterotomy. No other intervention had been performed because he hoped to avoid further treatment. On examination, there was abdominal distension and right lower abdominal tenderness. Laboratory studies showed a white cell count of 9290 cells/L; C-reactive protein of 3.18 mg/dL; and HbA1c of 6.9%. An abdominal X-ray film showed dilated loops of small intestine and air in the gallbladder. An abdominal CT scan demonstrated that a calcified 3 cm oval gallstone had impacted in the terminal ileum, causing upper gastrointestinal dilatation. Pneumobilia and cholecystoduodenal fistula were confirmed (Fig. 1). A diagnosis of gallstone ileus was made, and emergency laparoscopy-assisted enterolithotomy was performed on the following day. A 12 mm blunt trocar and two additional ports were positioned below the umbilicus and in the right and left lower abdomen, respectively. A gallstone was found to have impacted in the terminal ileum, the small intestine being dilated proximally. Because there were severe adhesions around the gallbladder, liver, omentum and peritoneum, fistula repair was not undertaken, only laparoscopy-assisted enterolithotomy being performed (Fig. 2). A minilaparotomy was performed by extending the midline incision below the umbilicus by 6 cm, and the gallstone was removed from the ileum through the extended incision. Longitudinal enterotomy was performed to extract the brown gallstone, which measured 39 mm × 28 mm, and the incision closed transversely using an Albert–Lembert suture. The patient resumed oral intake on postoperative day 5 and was discharged on
2210-2612/$ – see front matter © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijscr.2011.07.012
CASE REPORT – OPEN ACCESS Y. Shioi et al. / International Journal of Surgery Case Reports 3 (2012) 12–15
13
Fig. 1. Computed tomography findings. (a) A gallstone measuring 3 cm in the terminal ileum (arrow), (b) pneumobilia (arrowhead) and cholecystoduodenal fistula (arrow).
Fig. 2. Intraoperative findings. (a) Severe adhesions of gallbladder, omentum, and duodenum. (b) Laparoscopy-assisted enterolithotomy.
postoperative day 14 in spite of wound infection. One week after removal of the gallstone, esophago-gastro-duodenoscopy (EGD) revealed an erythematous cholecystoduodenal fistula with a white coating in the superior duodenal angulus (Fig. 3a). Two weeks later, an EGD confirmed that the fistula had closed spontaneously
(Fig. 3b) and an ERC performed simultaneously revealed that the cholecystoduodenal fistula had connected the infundibulum of the gallbladder to the second part of the duodenum (Fig. 4). No symptoms or liver dysfunction occurred during the 6-month follow up.
Fig. 3. Endoscopic findings. (a) One week after surgery: the inflamed orifice of the cholecystoduodenal fistula (arrow) in the superior duodenal angulus. (b) Two weeks after surgery: the cholecystoduodenal fistula (arrow) had closed.
CASE REPORT – OPEN ACCESS 14
Y. Shioi et al. / International Journal of Surgery Case Reports 3 (2012) 12–15
Fig. 4. Endoscopic retrograde cholangiography revealing that the cholecystoduodenal fistula had connected the infundibulum of the gallbladder to the second part of the duodenum.
3. Discussion Gallstone ileus, a rare complication of cholelithiasis, is a relatively rare cause of mechanical bowel obstruction, being found in 1–4% of cases.4–6 Because gallstone ileus is mainly a condition of elderly patients, there is a high rate of morbidity due to concomitant disease, resulting in a high mortality rate of from 6.7 to 22.7%.2–4,7 The pathophysiology of gallstone ileus is as follows. Acute or chronic cholecystitis associated with cholelithiasis, together with pressure from gallstones, causes inflammation and adhesions, facilitating the formation of a cholecystoenteric fistula.8 Cholecystoduodenal fistula is the most common type of cholecystoenteric fistula, less frequent types being cholecystocolonic and cholecystduodenocolonic.4,5 The diagnosis of gallstone ileus is still missed or delayed, an accurate preoperative diagnosis being made in only 77% of cases.7 The classical radiological triad for this diagnosis is pneumobilia, the presence of an ectopic gallstone and mechanical bowel obstruction.9 Advanced diagnostic imaging technology, such as multidetector computed tomography, allows direct visualization of cholecystoenteric fistulae, leading to a more precise diagnosis.10 There are three options for the surgical management of gallstone ileus. The first option is enterolithotomy with stone extraction alone. The second is a two-stage procedure, namely enterolithotomy followed by delayed elective cholecystectomy and fistula repair. The third is a one stage procedure, namely enterolithotomy, cholecystectomy and fistula repair.1 The selection of surgical procedure depends largely on the clinical status of the patient, enterolithotomy alone being advised if the patient is elderly and there are concomitant diseases.2,3,11,12 Definitive cholecystectomy and fistula closure is associated with a prolonged operative time and higher complication and mortality rates. Our patient was severely dehydrated and malnourished because he had taken nothing by mouth for 10 days. In addition, laparoscopy revealed severe adhesions around the gallbladder. Accordingly, we selected enterolithotomy alone in preference to one-stage surgery. Laparoscopy-assisted enterolithotomy for gallstone ileus, as used in the present case, allows simultaneous direct
diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract. We recommend laparoscopyassisted enterolithotomy for both diagnosis and treatment because it is less invasive than open surgery, and therefore results in fewer major complications.13 Patients with gallstone ileus who are elderly and have associated disease would particularly benefit from a laparoscopic approach. This case report describes diagnosis by endoscopy of spontaneous closure of a cholecystoduodenal fistula. Endoscopy can diagnose the location, status and circumference of a fistula by direct visualization. A few previous reports have described spontaneous closure of cholecystoduodenal fistulae.2,6 The procedure of enterolithotomy alone occasionally causes biliary complication such as chronic cholangitis leading to hepatic insufficiency, and the development of biliary carcinoma,6 but spontaneous closure of cholecystoduodenal fistulae may result in fewer such complications. Raf and Spangen recommended that delayed elective cholecystectomy and fistula repair should be performed during the quiet period 3–6 months after enterolithotomy for gallstone ileus.6 The time from onset of the gallstone ileus to closure of cholecystoduodenal fistula has not often been reported. Confirmation of fistulous closure by endoscopy after laparoscopy-assisted enterolithotomy may occasionally result in this minimally invasive procedure averting the need for biliary surgery. A search of articles published in English revealed that the process of spontaneous fistulous closure has rarely been described. Confirmation of fistula closure by the morphological appearance on endoscopy may contribute to more appropriate treatment in individual cases. 4. Conclusion We have presented here a case of gallstone ileus in which a cholecystoduodenal fistula had closed spontaneously by 2 weeks after enterolithotomy alone. We propose that the necessity for cholecystectomy and fistula repair should be assessed earlier than previously considered, because spontaneous closure of a fistula can occur within a month of onset of gallstone ileus. Conflict of interest statement The authors have no conflict of interests to declare. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. Funding None. Author contributions Yoshihiro Shioi contributed to data collections, data analysis, and writing. Shuji Kawamura, Kiminori Kanno, Yutaka Nishinari, Kousei Ikeda, Akihiro Noro, and Fumishi Kooka contributed to data collections. Acknowledgements This study had no source of funding.
CASE REPORT – OPEN ACCESS Y. Shioi et al. / International Journal of Surgery Case Reports 3 (2012) 12–15
References 1. Beuran M, Ivanov I, Venter MD. Gallstone ileus—clinical and therapeutic aspects. J Med Life 2010;3:365–71. 2. Lobo DN, Jobling JC, Balfour TW. Gallstone ileus: diagnostic pitfalls and therapeutic successes. J Clin Gastroenterol 2000;30:72–6. 3. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg 1994;60:441–6. 4. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg 1990;77:737–42. 5. Pavlidis TE, Atmatzidis KS, Papaziogas BT, Papaziogas TB. Management of gallstone ileus. J Hepatobiliary Pancreat Surg 2003;10:299–302. 6. Raf L, Spangen L. Gallstone ileus. Acta Chir Scand 1971;137:665–75. 7. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007;31:1292–7.
15
8. Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: a review. Mt Sinai J Med 2006;73:1132–4. 9. Rigler L, Borman C, Noble J. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941;117:1753–9. 10. Lassandro F, Romano S, Ragozzino A, Rossi G, Valente T, Ferrara I, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. Am J Roentgenol 2005;185:1159–65. 11. Doko M, Zovak M, Kopljar M, Glavan E, Ljubicic N, Hochstadter H. Comparison of surgical treatments of gallstone ileus: preliminary report. World J Surg 2003;27:400–4. 12. Riaz N, Khan MR, Tayeb M. Gallstone ileus: retrospective review of a single centre’s experience using two surgical procedures. Singapore Med J 2008;49: 624–6. 13. Moberg AC, Montgomery A. Laparoscopically assisted or open enterolithotomy for gallstone ileus. Br J Surg 2007;94:53–7.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.