Clavien P A, Richon J, Burgan S, Rohner A
Department of Surgery, University Hospital, Geneva, Switzerland.
Br J Surg. 1990 Jul;77(7):737-42. doi: 10.1002/bjs.1800770707.
Thirty-seven patients (33 women and four men, median age 78 years) were operated on for gallstone ileus over a 12-year period with a median follow-up of 6.2 years. Twenty-three patients (62 per cent) had serious concomitant diseases. Plain abdominal radiographs performed at admission were diagnostic in only 17 patients (46 per cent) and other procedures such as ultrasonography, gastrointestinal contrast studies and computed tomographic scan were required in ten patients (27 per cent). The diagnosis was made before operation in 27 patients (73 per cent) but in only 17 (46 per cent) at admission. Obstructing stones were located in the terminal ileum in 27 patients (73 per cent), in the proximal ileum or jejunum in five (14 per cent), in the duodenum in two (5 per cent), and in the colon in three (8 per cent). In six instances (16 per cent), more than one stone was involved. Cholecystduodenal fistula was the most frequent fistula type (n = 25, 68 per cent), followed by cholecystcolonic (n = 2, 5 per cent) and cholecystduodenocolonic (n = 2, 5 per cent) types. The site of the fistula was not established in the other eight instances. A one-stage procedure consisting of the removal of the impacted stone, fistula repair and cholecystectomy was performed in eight patients, two of whom died. A second group of six patients underwent a two-stage procedure consisting of enterolithotomy followed by elective biliary surgery, with no mortality. Removal of impacted stones was the only surgical treatment in the remaining 23 patients, with five deaths. Operative mortality and morbidity rates associated with the initial procedure did not differ significantly among the three therapeutic groups, which were comparable in terms of patient age, associated concomitant diseases and APACHE II score. However, later biliary complications were prominent in patients treated only by enterolithotomy. These results support the view that a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. When local or surgical conditions argue against a one-stage procedure, biliary surgery at a second stage should be considered, if residual stones are present. In poor risk patients, non-operative methods should be considered.
在12年期间，37例患者（33例女性，4例男性，中位年龄78岁）因胆石性肠梗阻接受了手术，中位随访时间为6.2年。23例患者（62%）患有严重的合并症。入院时进行的腹部平片仅对17例患者（46%）具有诊断价值，另外10例患者（27%）需要进行其他检查，如超声检查、胃肠道造影和计算机断层扫描。27例患者（73%）在手术前确诊，但入院时仅17例（46%）确诊。梗阻性结石位于回肠末端27例（73%），位于回肠近端或空肠5例（14%），位于十二指肠2例（5%），位于结肠3例（8%）。6例（16%）涉及不止一枚结石。胆囊十二指肠瘘是最常见的瘘管类型（n = 25，68%），其次是胆囊结肠瘘（n = 2，5%）和胆囊十二指肠结肠瘘（n = 2，5%）。其他8例未确定瘘管部位。8例患者接受了一期手术，包括取出嵌顿结石、修复瘘管和胆囊切除术，其中2例死亡。第二组6例患者接受了两期手术，包括肠石切除术，随后进行择期胆道手术，无死亡病例。其余23例患者仅接受了取出嵌顿结石的手术治疗，5例死亡。三个治疗组与初始手术相关的手术死亡率和发病率没有显著差异，在患者年龄、合并症和急性生理与慢性健康状况评分II（APACHE II）方面具有可比性。然而，仅接受肠石切除术治疗的患者后期胆道并发症较为突出。这些结果支持这样一种观点，即一期手术在可行时是一种有效的选择，可能是首选的手术方式。当局部或手术条件不适合一期手术时，如果存在残留结石，应考虑二期胆道手术。对于风险较高的患者，应考虑非手术方法。
