Disease spectrum and use of cholecystolithotomy in gallstone ileus

Background: Gallstone ileus is a heterogeneous and highly morbid condition that suffers from a lack of consensus regarding the timing and approach to management of the biliary tree and associated fistula. Methods: We report three cases that demonstrate the spectrum of gallstone ileus with classical examples of both Barnard's and Bouveret's syndromes. Clinical presentation, diagnostic imaging, surgical technique and outcome are discussed. Results: One patient with Barnard's syndrome presented with recurrent gallstone ileus. To minimize the risks of complex, definitive biliary surgery and avoid further recurrent episodes, a cholecystolithotomy was performed with effect. Two cases of Bouveret's syndrome were successfully managed with enterolithotomy/cholecystectomy and multivisceral resection respectively, thus highlighting the diverse nature of this disease and management options. Conclusions: Following enterolithotomy, potentially morbid, definitive one-stage surgery in typically compromised, elderly patients needs to be weighed against the risk of recurrence and ongoing biliary pathology. We suggest the use of open cholecystolithotomy for the removal of residual gallstones when the patient is not suitable for definitive biliary surgery.